Integrating Nutrition Actions in Service Delivery: The Practices of Frontline Workers in Uganda

Document Type : Original Article

Authors

1 Public Administration and Policy Group, Wageningen University & Research, Wageningen, The Netherlands

2 Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands

3 Institute of Development Studies, University of Sussex, Brighton, UK

Abstract

Background 
Integrating nutrition actions into service delivery in different policy sectors is an increasing concern. Nutrition literature recognizes the discrepancies existing between policies as adopted and actual service delivery. This study applies a street-level bureaucracy (SLB) perspective to understand frontline workers’ practices that enact or impede nutrition integration in services and the conditions galvanizing them.

Methods 
This qualitative exploratory study assesses the contextual conditions and practices of 45 frontline workers employed by the agriculture, health and community development departments in two Ugandan districts.

Results 
Frontline workers incur different demands and resources arising at societal, organizational, and individual level. Hence, they adopt nine co-existing practices that ultimately shape nutrition service delivery. Nutrition integration is accomplished through: (1) ritualizing task performance; (2) bundling with established services; (3) scheduling services on a specific day; and (4) piggybacking on services in other domains. Disintegration results from (5) non-involvement and (6) shifting blame to other entities. Other practices display both integrative and disintegrative effects: (7) creaming off citizens; (8) down prioritization by fixating on a few nutrition actions; and (9) following the bureaucratic ‘jobs worth’. Integrative practices are driven mostly by donors.

Conclusion 
Understanding frontline workers’ practices is crucial for identifying policy solutions to sustain nutrition improvements. Sustaining services beyond timebound projects necessitates institutionalizing demands and resources within government systems. Interventions to facilitate effective nutrition service delivery should strengthen the integrative capacities of actors across different government levels. This includes investing in integrative leadership, facilitating frontline workers across sectors to provide nutrition services, and adjusting the nutrition monitoring systems to capture cross-sector data and support policy learning.

Keywords

References

  1. Fanzo J, Hawkes C, Udomkesmalee E, et al. 2018 Global Nutrition Report: Shining a Light to Spur Action on Nutrition. Bristol, UK: Development Initiatives; 2018.
  2. World Health Organization (WHO). Global Nutrition Policy Review: What Does It Take to Scale Up Nutrition Action? WHO; 2013:124.
  3. Menon P, Avula R, Pandey S, Scott S, Kumar A. Rethinking effective nutrition convergence: an analysis of intervention co-coverage data. Econ Polit Wkly. 2019;54(24):18-21.
  4. Tumilowicz A, Ruel MT, Pelto G, et al. Implementation science in nutrition: concepts and frameworks for an emerging field of science and practice. Curr Dev Nutr. 2019;3(3):nzy080. doi:1093/cdn/nzy080
  5. Casado-Asensio J, Steurer R. Mitigating climate change in a federal country committed to the Kyoto Protocol: how Swiss federalism further complicated an already complex challenge. Policy Sci. 2016;49(3):257-279. doi:1007/s11077-016-9247-z
  6. Candel JJL. The expediency of policy integration. Policy Stud. 2021;42(4):346-361. doi:1080/01442872.2019.1634191
  7. Wanzira H, Muyinda R, Lochoro P, et al. Quality of care for children with acute malnutrition at health center level in Uganda: a cross sectional study in West Nile region during the refugee crisis. BMC Health Serv Res. 2018;18(1):561. doi:1186/s12913-018-3366-5
  8. Nsiah-Asamoah C, Pereko KKA, Intiful FD. Nutritional counselling interactions between health workers and caregivers of children under two years: observations at selected child welfare clinics in Ghana. BMC Health Serv Res. 2019;19(1):817. doi:1186/s12913-019-4692-y
  9. Fanzo J, Marshall Q, Dobermann D, et al. Integration of nutrition into extension and advisory services: a synthesis of experiences, lessons, and recommendations. Food Nutr Bull. 2015;36(2):120-137. doi:1177/0379572115586783
  10. Lipsky M. Street-Level Bureaucracy: Dilemmas of the Individual in Public Service. 30th Anniversary Expanded Edition ed. Russell Sage Foundation; 2010:274.
  11. Salam RA, Das JK, Bhutta ZA. Integrating nutrition into health systems: what the evidence advocates. Matern Child Nutr. 2019;15(Suppl 1):e12738. doi:1111/mcn.12738
  12. Nisbett N, van den Bold M, Gillespie S, et al. Community-level perceptions of drivers of change in nutrition: evidence from South Asia and sub-Saharan Africa. Glob Food Sec. 2017;13:74-82. doi:1016/j.gfs.2017.01.006
  13. Hupe P, Buffat A. A public service gap: capturing contexts in a comparative approach of street-level bureaucracy. Public Manag Rev. 2014;16(4):548-569. doi:1080/14719037.2013.854401
  14. Hoddinott J. The Economics of Reducing Malnutrition in Sub-Saharan Africa. Global Panel on Agriculture and Food Systems for Nutrition Working Paper. 2016:21.
  15. UBOS, ICF. Uganda Demographic and Health Survey 2016. UBOS, ICF; 2018.
  16. Namugumya BS, Candel JJL, Talsma EF, Termeer CJAM. Towards concerted government efforts? Assessing nutrition policy integration in Uganda. Food Secur. 2020;12(2):355-368. doi:1007/s12571-020-01010-5
  17. Turcan L, Bene T. A Review of Policies for Improving Human Nutrition in Uganda and the Use of Evidence for Making Policy. Montpellier, France: National Information Platforms for Nutrition (NIPN); 2017.
  18. Cejudo GM, Michel CL. Addressing fragmented government action: coordination, coherence, and integration. Policy Sci. 2017;50(4):745-767. doi:1007/s11077-017-9281-5
  19. Barling D, Lang T, Caraher M. Joined–up food policy? The trials of governance, public policy and the food system. Soc Policy Adm. 2002;36(6):556-574. doi:1111/1467-9515.t01-1-00304
  20. Christensen T, Lægreid P. The whole-of-government approach to public sector reform. Public Adm Rev. 2007;67(6):1059-1066. doi:1111/j.1540-6210.2007.00797.x
  21. Bennett S, Glandon D, Rasanathan K. Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge. BMJ Glob Health. 2018;3(Suppl 4):e000880. doi:1136/bmjgh-2018-000880
  22. Singer SJ, Kerrissey M, Friedberg M, Phillips R. A comprehensive theory of integration. Med Care Res Rev. 2020;77(2):196-207. doi:1177/1077558718767000
  23. Pomeroy-Stevens A, D'Agostino A, Adero N, et al. Prioritizing and Funding the Uganda Nutrition Action Plan. Food Nutr Bull. 2016;37(4 Suppl):S124-S141. doi:1177/0379572116674554
  24. Food and Agriculture Organization (FAO). Nutrition-Sensitive Agriculture and Food Systems in Practice Options for Intervention. FAO; 2017:239.
  25. Ruel MT, Alderman H. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet. 2013;382(9891):536-551. doi:1016/s0140-6736(13)60843-0
  26. Bhutta ZA, Das JK, Rizvi A, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382(9890):452-477. doi:1016/s0140-6736(13)60996-4
  27. Tummers LLG, Bekkers V, Vink E, Musheno M. Coping during public service delivery: a conceptualization and systematic review of the literature. J Public Adm Res Theory. 2015;25(4):1099-1126. doi:1093/jopart/muu056
  28. Brodkin EZ. Policy work: street-level organizations under new managerialism. J Public Adm Res Theory. 2011;21(Suppl 2):i253-i277. doi:1093/jopart/muq093
  29. Belabas W, Gerrits L. Going the extra mile? How street-level bureaucrats deal with the integration of immigrants. Soc Policy Adm. 2017;51(1):133-150. doi:1111/spol.12184
  30. Hill HC. Understanding implementation: street‐level bureaucrats' resources for reform. J Public Adm Res Theory. 2003;13(3):265-282. doi:1093/jpart/mug024
  31. Ling T, Brereton L, Conklin A, Newbould J, Roland M. Barriers and facilitators to integrating care: experiences from the English Integrated Care Pilots. Int J Integr Care. 2012;12:e129. doi:5334/ijic.982
  32. Evans JM, Grudniewicz A, Baker GR, Wodchis WP. Organizational context and capabilities for integrating care: a framework for improvement. Int J Integr Care. 2016;16(3):15. doi:5334/ijic.2416
  33. Fuertes V, Lindsay C. Personalization and street‐level practice in activation: the case of the UK's work programme. Public Adm. 2016;94(2):526-541. doi:1111/padm.12234
  34. Mosse D. Is good policy unimplementable? Reflections on the ethnography of aid policy and practice. Dev Change. 2004;35(4):639-671. doi:1111/j.0012-155X.2004.00374.x
  35. Namugumya BS, Candel JJ, Talsma EF, Termeer CJ. A mechanisms-based explanation of nutrition policy (dis)integration processes in Uganda. Food Policy. 2020;92:101878. doi:1016/j.foodpol.2020.101878
  36. Harris J. Advocacy coalitions and the transfer of nutrition policy to Zambia. Health Policy Plan. 2019;34(3):207-215. doi:1093/heapol/czz024
  37. Pelletier D, Gervais S, Hafeez-Ur-Rehman H, Sanou D, Tumwine J. Boundary-spanning actors in complex adaptive governance systems: the case of multisectoral nutrition. Int J Health Plann Manage. 2018;33(1):e293-e319. doi:1002/hpm.2468
  38. WFP, UNICEF. Food Security and Nutrition Assessment in Karamoja Sub-Region. WFP, UNICEF; 2017:102. https://docs.wfp.org/api/documents/WFP-0000022487/download/?iframe. Accessed January 2019.
  39. Karamoja Resilience Support Unit (KRSU). Karamoja Donor Mapping Report. 2016. Karamoja Resilience Support Unit, USAID/Uganda. Karamoja NGO Mapping. https://karamojaresilience.org.
  40. Kuziga F, Adoke Y, Wanyenze RK. Prevalence and factors associated with anaemia among children aged 6 to 59 months in Namutumba district, Uganda: a cross- sectional study. BMC Pediatr. 2017;17(1):25. doi:1186/s12887-017-0782-3
  41. Museveni YK. Uganda Nutrition Action Plan 2011-2016: Scaling Up Multi-Sectoral Efforts to Establish a Strong Nutrition Foundation for Uganda's Development. Kampala, Uganda: Government of Uganda; 2011.
  42. Timmermans S, Tavory I. Theory construction in qualitative research: from grounded theory to abductive analysis. Sociol Theory. 2012;30(3):167-186. doi:1177/0735275112457914
  43. Lyth IM. The functioning of social systems as a defence against anxiety: a report on a study of the nursing service of a general hospital. In: Lyth IM, ed. Containing Anxiety in Institutions: Selected Essays. Vol 269. Free Association Books; 1988.
  44. Harrison T, Kostka G. Balancing priorities, aligning interests: developing mitigation capacity in China and India. Comp Polit Stud. 2014;47(3):450-480. doi:1177/0010414013509577
  45. Ickovics JR. "Bundling" HIV prevention: integrating services to promote synergistic gain. Prev Med. 2008;46(3):222-225. doi:1016/j.ypmed.2007.09.006
  46. Gupta D, Denton B. Appointment scheduling in health care: challenges and opportunities. IIE Trans. 2008;40(9):800-819. doi:1080/07408170802165880
  47. Terpstra V, Yu CM. Piggybacking: a quick road to internationalisation. Int Mark Rev. 1990;7(4). doi:1108/02651339010000299
  48. Robinson TN. Save the world, prevent obesity: piggybacking on existing social and ideological movements. Obesity (Silver Spring). 2010;18 Suppl 1:S17-22. doi:1038/oby.2009.427
  49. Høiland G, Willumsen E. Resistance-driven innovation? Frontline public welfare workers’ coping with top-down implementation. Nord J Work Life Stud. 2018;8(2):1-20. doi:18291/njwls.v8i2.106153
  50. Organ DW, Greene CN. The effects of formalization on professional involvement: a compensatory process approach. Adm Sci Q. 1981;26(2):237-252. doi:2307/2392471
  51. Hood C. The Blame Game: Spin, Bureaucracy, and Self-Preservation in Government. Princeton University Press; 2011.
  52. Embuldeniya G, Kirst M, Walker K, Wodchis WP. The generation of integration: the early experience of implementing bundled care in Ontario, Canada. Milbank Q. 2018;96(4):782-813. doi:1111/1468-0009.12357
  53. Gillespie S, van den Bold M. Stories of change in nutrition: an overview. Glob Food Sec. 2017;13:1-11. doi:1016/j.gfs.2017.02.004
  54. Asad AL, Kay T. Theorizing the relationship between NGOs and the state in medical humanitarian development projects. Soc Sci Med. 2014;120:325-333. doi:1016/j.socscimed.2014.04.045
  55. Storeng KT, Palmer J, Daire J, Kloster MO. Behind the scenes: International NGOs' influence on reproductive health policy in Malawi and South Sudan. Glob Public Health. 2019;14(4):555-569. doi:1080/17441692.2018.1446545
  56. Sodjinou R, Bosu WK, Fanou N, et al. A systematic assessment of the current capacity to act in nutrition in West Africa: cross-country similarities and differences. Glob Health Action. 2014;7:24763. doi:3402/gha.v7.24763
  57. Evans JM, Baker GR, Berta W, Barnsley J. The evolution of integrated health care strategies. Adv Health Care Manag. 2013;15:125-161. doi:1108/s1474-8231(2013)0000015011
  58. Webb P, Kennedy E. Impacts of agriculture on nutrition: nature of the evidence and research gaps. Food Nutr Bull. 2014;35(1):126-132. doi:1177/156482651403500113
International Journal of Health Policy and Management
Volume 11, Issue 12
December 2022
Pages 2895-2906

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History

  • Receive Date: 15 January 2021
  • Revise Date: 06 March 2022
  • Accept Date: 30 March 2022
  • First Publish Date: 03 April 2022

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