complicating or complementing? - wur
TRANSCRIPT
Complicating or Complementing?
The Effects of Decentralisation on Policy Integration of
Nutrition Policy at District Level in Uganda
Anouk de Vries
Msc Thesis, October 2019
Complicating or Complementing?
The Effects of Decentralisation on Policy Integration of
Nutrition Policy at District Level in Uganda
Msc Thesis, October 2019
Student Anouk de Vries
Registration number 950303911050
MSc Program International Development Studies
Specialisation Politics & Governance, Sustainable Development Diplomacy
Chair Group Public Administration and Policy
Supervisors BS Shenute Namugumya, Dr. JJL Candel
Second reader Prof. dr. ir. Katrien Termeer
Thesis code PAP-80336
Cover photo by Anouk de Vries, field visit in Ntungamo District, Uganda, August 2018
PREFACE
On the 19th of July 2018, after a long flight, I landed at Entebbe airport. On my own, with little idea
what to expect of the field research I was going to do or what the country that I was going to spend the
coming two months looked like. Looking back, my time in Uganda was amazing. I was lucky enough
to not just do research, but feel part of daily life in Uganda.
There is one person that I own the world for this, which is Nadith. Thanks for accepting me into your
home and family, helping me with my research and showing me what life in Uganda looks like. My time
in Uganda, nor this thesis, would have been nearly as great without you. The same counts for Monic,
Phiona, DJ and baby Mark. All of you have made me feel welcome and at home, one of the most special
things there is.
I would also like to thank Brenda and Jeroen for trying to answer all of my questions and help me to
move in the right direction. This was not always easy, but I really appreciate your patience, the time and
effort you have put into it and your advice. A special thanks for Brenda for also providing me with a
great network in Uganda, so that I was always safe, looked after and knew what do to and whom to
contact.
Last but not least, lieve papa en mama, lieve Thijm, wat fijn dat jullie er altijd zijn. Om even het extra
duwtje te geven als dat nodig is, me alle kansen te gunnen die er zijn en de successen mee te vieren. You
mean the world to me.
In front of me is now a thesis that brings me to the end (at least for now) of my academic career. I am
grateful for having had access to great education, with all the opportunities that came along with it.
Where one door closes there is always a next one that opens. After six years of studying I can now say
with full confidence that I am ready for the next step.
Anouk de Vries
ABSTRACT
Nutrition is recognized to be important for development but progress is slow and many people
worldwide still suffer from the consequences of malnutrition. One of the reasons for this is that policy
making and implementation of nutrition policy is challenging. Using a policy integration approach can
improve this. However, there is little empirical evidence on the dynamics of policy integration for
nutrition policies in different types of governance systems, such as a decentralised system. Taking
Uganda as a case study this research aims to contribute to this gap in the literature by answering the
following question: ‘What are the effects of decentralisation on the policy integration process of
nutrition policy at district level in Uganda?’. Uganda was selected for this study because of its poor
nutrition situation, its highly decentralised governance setting and the implementation of the Uganda
Nutrition Action Plan. Data was gathered by conducting 26 interviews with relevant stakeholders and
collecting relevant (policy) documents. This data was analysed by making an analysis the four
dimensions of policy integration as defined by Candel & Biesbroek (2016) and assessing the influence
of decentralisation on each of these four dimensions.
Results show that the overall level of policy integration is low to medium. Positive aspects are a good
understanding of the multi-sectoral nature of nutrition among stakeholders, the existence of a
coordinating body and political attention. The aspects that have the strongest negative influence on
policy integration are the sectoral structure in the governance system, the domination of one
coordinating body (the District Nutrition Coordination Committee), the lack of political commitment
and the desynchronized policy objectives and policy instruments in different documents. Effects of
decentralisation were especially seen in relation to the lack of coordination between government levels
and the lack of consultation of lower government levels. The effects were predominantly negative, with
the exception of leadership that was enabled by decentralisation. Therefore, it is argued that
decentralisation is a complicating factor in the process of achieving a high level of policy integration.
Key words: nutrition, nutrition policy, policy integration, decentralisation, Uganda Nutrition Action
Plan, lower level governments
TABLE OF CONTENT
CHAPTER 1: INTRODUCTION............................................................................................................ 8
CHAPTER 2: CONCEPTUAL FRAMEWORK .................................................................................. 13
2.1 Policy Integration ........................................................................................................................ 13
2.2 Decentralisation ........................................................................................................................... 19
2.3 Concluding Remarks ................................................................................................................... 26
CHAPTER 3: RESEARCH DESIGN AND METHODOLOGY.......................................................... 28
3.1 Ntungamo District as a Case Study ............................................................................................. 28
3.2 Criteria for selecting the sub-counties in Ntungamo District ...................................................... 28
3.3 Data Collection Methods ............................................................................................................. 33
3.4 Data Analysis .............................................................................................................................. 35
3.5 Reflections on the Research Design and Methodology ............................................................... 37
CHAPTER 4 - RESULTS ..................................................................................................................... 40
4.1 Analysis of the Level of Policy Integration ................................................................................. 40
4.2 The Effects of Decentralisation on Policy Integration ................................................................ 56
CHAPTER 5 – CONCLUSION AND DISCUSSION .......................................................................... 64
5.1 Conclusion ................................................................................................................................... 64
5.2 Discussion ................................................................................................................................... 65
5.3 Limitations................................................................................................................................... 69
5.4 Recommendations for Policy Makers ......................................................................................... 70
BIBLIOGRAPHY ................................................................................................................................. 72
APPENDICES ....................................................................................................................................... 76
Appendix 1: Interview list ................................................................................................................. 76
Appendix 2: Interview script ............................................................................................................. 77
Appendix 3: Overview of documents acquired during fieldwork ..................................................... 80
Appendix 4: Overview of full list of codes used for data analysis .................................................... 81
Appendix 5: Overview financial structures Ntungamo District ........................................................ 82
Appendix 6: Overview attendance DNCC meetings ......................................................................... 83
LIST OF ABBREVIATIONS
CSO Civil Society Organisation
DDP District Development Plan
DNAP District Nutrition Action Plan
DNCC District Nutrition Coordination Committee
EPI Environmental Policy Integration
FANTA Food and Nutrition Technical Assistance
LC Local Council
MSNAP Multi-Sectoral Nutrition Action Plan
NGO Non-Governmental Organisation
NPM New Public Management
UDHS Uganda Demographic and Health Survey
UMFSNP Uganda Multi-Sectoral Food Security and Nutrition Project
UNAP Uganda Nutrition Action Plan
SDG Sustainable Development Goal
SNCC Sub-county Nutrition Coordination Committee
SUN Scaling Up Nutrition
LIST OF TABLES AND FIGURES
Table 1: Level of Stunting in the sub-counties of Ntungamo District 30
Table 2: Number of NGOs active per sub-county (before interviews) 30
Table 3: Number of NGOs active per sub-county (after interviews) 32
Table 4: Comparison of policy objectives in the DNAP and the DDP 51
Figure 1: UNICEF conceptual framework of the determinants of child undernutrition 9
Figure 2: The Local Government Structure in Uganda 20
Figure 3: Visualisation of the operationalisation of the Policy Integration dimensions 26
Figure 4: Visualisation of the operationalisation decentralisation in relation to policy integration 27
Figure 5: Sub-county selection matrix before interviews 31
Figure 6: Sub-county selection matrix after interviews 32
Figure 7: Schematic visualization of an example of the connection between data collection
methods and the theoretical concepts 34
Figure 8: Schematic visualization of steps in the data analysis process 36
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CHAPTER 1: INTRODUCTION
In the 2018 Global Nutrition Report it is stated that ‘good health is not possible without good nutrition’,
making nutrition essential for development (Development Initiatives, 2018, p. 21). Despite of this
malnutrition remains a global problem that expresses itself in different ways. Undernutrition, especially
stunting and micronutrient deficiencies, affect respectively around 150 million children and 2 billion
people worldwide. Maternal and child malnutrition during the first 1,000 days (between conception and
24 months) can significantly hinder a child’s cognitive development, resulting in lower productivity
both in school and later on in work life. Around 45 percent of all deaths among children under five in
low and middle-income countries is explained by undernutrition (Benson, 2008; Black et al., 2013;
Development Initiatives, 2018; Smith & Haddad, 2015). Particularly in Sub-Saharan Africa and South
Asia, progress on stunting is slow. It is estimated that between 1.9 percent and 16.5 percent of the annual
Gross Domestic Product (GDP) of African countries is lost as a result of malnutrition. Malnutrition
therefore does not only form a threat to one’s health, but also to one’s social and economic development
(Development Initiatives, 2017; Smith & Haddad, 2015; Webb et al., 2018).
For a long time malnutrition was not recognized as a significant obstacle to development, even though
Freedom from hunger and malnutrition is included in the 1948 Universal Declaration of Human Rights.
It was commonly understood to be a health problem, which could be resolved by taking away sources
of disease or improving food intake. However, this is a misunderstanding, as malnutrition is caused by
problems in different sectors and at different levels. A multi-sectoral approach allows for grasping the
full complexity of the matter. This is demonstrated by the three levels of causes of undernutrition in the
‘UNICEF conceptual framework of the determinants of child nutrition’, the most commonly used
framework to assess nutrition situations (see figure 1). The basic causes are the larger socio-economic
dynamics that have significant influence on a person’s nutrition situation. One of the basic causes is
political context, which demonstrates that malnutrition is rooted in the wider structural problems of
poverty and inequality in society (Acosta & Fanzo, 2012; Benson, 2008, p. 14-16; Nisbett et al., 2014).
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Figure 1: UNICEF conceptual framework of the determinants of child undernutrition (UNICEF, 2015)
In the early 2000s, increasing attention for malnutrition started to emerge. Millennium Development
Goal 1 included an indicator on reducing the prevalence of underweight in children. Additional attention
followed with the publication of two Lancet series on maternal and child malnutrition published in 2008
and 2013 (Hoey & Pelletier, 2011; Gillespie, 2013; UNICEF, 2014). Simultaneously, action was
undertaken in the political domain. In 2008, the High Level Taskforce on Food and Nutrition Security
was held, followed by the World Summit on Food Security in 2009. The Scaling Up Nutrition (SUN)
initiative, still considered one of the most important nutrition movements globally, was set up in 2010
(Gillespie, 2013; SUN movement). In the Sustainable Development Goals (SDGs) the importance of
nutrition has once again been underlined, by including it as a target that is part of SDG 2 ‘End hunger,
achieve food security and improved nutrition and promote sustainable agriculture’ (United Nations). It
is now safe to say that the importance of nutrition has been clearly established and is globally recognized.
However, even with more attention, policy making and implementation for malnutrition problems has
proven to be challenging. The 2018 Global Nutrition Report concludes that policy implementation often
remains inadequate and there is a lack of action across sectors (Development Initiatives, 2018). Looking
at how nutrition is institutionally embedded, it is often said to be an institutional orphan. No country in
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the world has a ministry of nutrition and often, there is no ministry in the lead on nutrition. Therefore,
there is no single actor or institution that can be held accountable for nutrition problems in a country.
As Heaver (2005, p. 5) puts it, this leads to a situation where ‘In theory, nutrition is everyone’s business,
but because it is rarely the central concern of any one ministry or department, in practice it can become
nobody’s business.’. Or in other words, it is a secondary priority of all and the core responsibility of
none. This makes nutrition a misfit in currently existing institutional governance structures (Benson,
2008; Gillespie, 2013; Natalicchio et al., 2009). On top of that malnutrition, especially in its chronic
form of stunting, is a problem of low visibility. The symptoms are not easy to spot without knowledge
of the problem and people themselves are often not even aware they are affected. They are therefore not
organised and do not demand action. This invisibility and lack of organisation contributes to the lack of
pressure on governments to act on nutrition issues (Benson, 2008; Heaver, 2005; Hoey & Pelletier, 2011;
Natalicchio et al., 2009).
Altogether, the issue of malnutrition can therefore best be defined as a complex problem. Such a problem
has multiple and often interacting causes. The exact definition can change over time and is context-
dependent. Improving or solving complex problems requires the involvement of several policy sectors,
as there are no simple technological fixes. Therefore, such cases often do not fit in established patterns
of political or administrative governance systems (Briassoulis, 2004; Casado-Asensio & Steurer; 2014;
Cejudo & Michel, 2017). Applying these characteristics to malnutrition, there are many similarities. As
can be seen in the UNICEF framework (figure 1), the variables that cause malnutrition are multiple and
connected and can change over time. Technological fixes will therefore not suffice to solve the issue.
Implementing actors often struggle with administrative and political barriers and wider governance
issues such as leadership and agenda control, when working to improve a community’s nutrition
situation (Natalicchio et al., 2009; Pelletier et al., 2011). In the political sphere, it is difficult to determine
which actors carry the responsibility, as malnutrition does not fit in existing structures. To make
meaningful steps towards improvement, different policy sectors need to be involved (Heaver, 2005).
Over the years, the consensus among academia that a policy integration approach is suitable for the
complex problem of malnutrition emerged. Several countries in Sub-Saharan Africa now have a
national food or nutrition security program or policy which uses an integrated policy approach (Candel,
2018). In theory, this allows for coherence between and cooperation among actions of different
(government) institutions (Development Initiatives, 2017; Gillespie, 2013). However, evidence on the
dynamics of policy integration for nutrition policies in different governance structures is limited. Two
gaps in the literature were identified. Firstly, there is little empirical evidence about policy integration
of nutrition policies in practice that can guide countries on how implementation can best be done. The
available research is descriptive rather than analytical and mostly discusses the policy on paper, but not
implementation on the ground (Garrett, Bassett & Levinson, 2011; Gillespie & van den Bold, 2017;
Harris & Drimie, 2012). Secondly, not all types of governance systems in which policy integration can
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be implemented are equally well researched. To the researcher’s knowledge, no research has been
conducted on the dynamics of policy integration of nutrition policy in a decentralised governance
setting. The multi-sectoral nature of nutrition has the potential to be problematic in combination with
decentralisation. Having to work across levels and departments in a governance system where these by
the nature of the system have a rather autonomous position can be a complicating factor. Therefore, an
analysis of the process of policy integration of nutrition policy in a decentralised governance system
makes for an important contribution to these literature gaps. The research will yield information that
allows for theory building on the relation between policy integration of nutrition policy and
decentralisation in a developing context.
Uganda makes for an excellent case for this research because of its malnutrition situation, the
implementation of the Uganda Nutrition Action Plan (the UNAP) and its non-western setting. At
national level Uganda produces enough food to meet the needs of its rapidly growing population
(FANTA-2, 2010). However, malnutrition remains a problem. According to the Uganda Demographic
and Health Survey (UDHS) the percentage of children that are stunted was 33% in 2011 and had
decreased to 29% in 2016. However, anaemia, which is one of the most common micronutrient
deficiencies, increased over the last decade both for children and women of reproductive age (Uganda
Bureau of Statistics and ICF, 2017; USAID, 2018). In response to its high malnutrition statistics the
UNAP was introduced in 2011. In the UNAP malnutrition is explicitly recognized as a complex problem
for which a policy integration approach is needed and various objectives that together should lead to
improving the nutrition situation are formulated. In the context of this research objective four is most
relevant, which states the following: ‘Strengthen the policy, legal, and institutional frameworks and the
capacity to effectively plan, implement, monitor, and evaluate nutrition programmes’ (Government of
Uganda, 2011, p. 19). Strategies are outlined to operationalise this objective. One of these, strategy 4.2,
aims to both strengthen and harmonize the institutional structure for nutrition at all levels from local to
central governments (p. 20). Also in the coordination arrangements for the implementation framework
of the UNAP the lower government level is explicitly addressed (Government of Uganda, 2011;
Pomeroy-Stevens et al., 2016). This indicates that the central government strives for active participation
of local governments to implement nutrition policy.
However, Uganda also has one of the most decentralised governance systems in the world. This means
that on paper local government levels have far-reaching administrative, political and financial autonomy,
making them relatively independent units within the Ugandan governance structure (Ojambo, 2012).
Even though the UNAP strives to actively involve local government levels, Uganda’s decentralised
system can be a complicating factor because lower government levels are largely autonomous and thus
have much freedom to decide on their own priorities. Whether implementation of a policy using a policy
integration approach is feasible in a decentralised governance system is therefore questionable. It is
therefore relevant to examine how decentralisation influences the process of policy integration at district
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level, which is the highest lower government level in Uganda’s decentralised structure. This, combined
with the previously identified gaps in the academic literature, leads to the following research question:
What are the effects of decentralisation on the policy integration process of nutrition policy at
district level in Uganda?
To answer the research question, an exploratory single N-case study approach is used. A case study
approach is ideal because the behaviour of the research objects cannot be manipulated, the contextual
conditions are highly relevant and the boundaries between the phenomenon and the context are not clear-
cut (Baxter & Jack, 2008). The choice for a single-N case study has been made because the research is
exploratory in nature and therefore needs an in-depth analysis of all possibly relevant factors. Too little
is known about the relation between the main concepts to formulate and test hypotheses or propositions
that for example are of a comparative nature. The scarcely available literature that is available is used to
formulate some first expectations that guide the data collection process. These expectations serve as a
starting point to explore the effects of decentralisation on policy integration. Findings will not be limited
to phenomena described in the existing literature. Rather, the aim of this research is work on theory
building. The data should generate new information that provides points for future research (Baxter &
Jack, 2008). The research is thereby abductive in nature, meaning it combines what is already known
with new information and based on this continues to build theory. Therefore, an exploratory case study
with an in-depth analysis which allows for new discoveries makes for a good fit.
The case chosen within Uganda is Ntungamo district. To observe the effects of decentralisation
interactions between the district and central and sub-county government levels are looked at. Ntungamo
was selected based on the relatively poor nutrition situation and the stability of its governance structure,
which seems to have not been affected by major changes over the past years (Government of Uganda &
Ntungamo District). This makes is more likely that the effects of decentralisation, rather than of other
governance processes, can be observed. The data gathered in this research is analysed in two steps. First,
policy integration is assessed using a framework of four dimensions of policy integration defined by
Candel & Biesbroek (2016). These dimensions are frames, subsystems, policy goals and policy
instruments. After that expectations of the possible effects of decentralisation on the policy integration
process are formulated. These expectations are used as a starting point that guides the direction of data
collection. The data has been gathered by conducting 26 interviews with stakeholders working on
nutrition in Ntungamo, both at district and sub-county level as well as non-governmental organisations.
In addition to this, information has been gathered from relevant (policy) documents. In the analysis, the
level of policy integration is determined based on assessing the level of integration for each of the four
dimensions. After that, the effects of decentralisation are determined by evaluating the four expectations
and identifying any possible other effects. Based on this, the research question is answered and
recommendations for further research as well as for policy makers are formulated.
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CHAPTER 2: CONCEPTUAL FRAMEWORK
2.1 Policy Integration
2.1.1 The emergence and definition of policy integration
In the 1970s and 1980s New Public Management (NPM) was the most common approach used to set up
and structure governmental institutions. Public organisations were organised into separate units which
each had their own role, managed their own issues and produced their own public sector products. It
was therefore also a dominant influence on the type of policies that were designed during this time
period. The main influence of NPM on policy design were that the policies created had a single purpose.
It was believed that this would result in a higher level of efficiency and specialization (Christensen &
Lægreid, 2011; Hood, 1995; Nordbeck & Steurer, 2016). However, it soon became clear that NPM
strategies were in many cases not capable to address policy issues and results were unsatisfactory.
Government action was often fragmented and uncoordinated, leading to competition rather than
cooperation. NPM hampered efficiency and resulted in silo structures, that operated in a fragmented and
uncoordinated manner (Cejudo & Michel, 2017; Christensen & Lægreid, 2007; Christensen & Lægreid,
2011; Nordbeck & Steurer, 2016).
From the 1990s onwards complex problems became more common and recognized. A complex problem
is an issue that has multiple and often interacting causes. Its nature can change over time and improving
it requires the involvement of several policy sectors. Therefore, NPM was no longer sufficient and a
different policy approach was needed. A policy approach that guided and consolidated various
government actions aimed at addressing the complex problem was sought and policy integration seemed
a good solution. Policy integration is in this research defined based on a combination of definitions given
in articles written by Candel (2017 and 2018), Candel & Biesbroek (2016) and Cejudo & Michel (2017).
It is the process of explicit governmental actions that aims to create multi-dimensional policy and
institutional change. This shapes the governance system in such a way that it is able to address multi-
sectoral or complex policy problems. The policy does include, but exceeds the individual goals of the
stakeholders in the governance system (Candel, 2017; Candel, 2018, Candel & Biesbroek, 2016; Cejudo
& Michel, 2017). Important to note is that the definition given is not outcome- but process-oriented. It
focuses on the on-the-ground situation, not the desired outcomes of the policy. The policy integration
approach stands in stark contrast with NPM. Whereas NPM policies often resulted in pillarization and
fragmentation, policy integration works across organisational boundaries, brings stakeholders together
and thereby aims to create a more efficient and effective public service. Policy Integration thus aims to
be truly innovative by addressing policy issues in a completely different way from what was previously
done (Christensen & Lægreid, 2007; Christensen & Lægreid, 2011).
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2.1.2 Horizontal and vertical policy integration
Policy integration can be analysed from two perspectives, namely vertically and horizontally. Horizontal
integration concerns the integration across different sectors, ministries, public agencies and/or others
stakeholders at one (government) level. Vertical integration is the cooperation between all these actors
across different (government) levels. It generally concerns the transmission of policy from the level
where it was designed to lower levels (Briassoulis, 2004; Charbit, 2011; Stead & Meijers, 2009). Peters
(2015) argues that to fully understand processes of policy integration, both horizontal and vertical
integration should be assessed. Similar to this, Howlett & Del Rio (2015) argue that one first needs to
understand both the horizontal and vertical design spaces and their interaction before one can understand
the purpose and functionality of certain mixes of policies and policy instruments. However, there is
barely any research available which has looked at questions around the relationship and trade-offs
between the different types of integration. Egeberg & Trondal (2015) have theorized this based on
empirical research they conducted on the interactions between the European Union agencies and
national members states. Based on this they proposed the coordination dilemma, in which they argue
that it is impossible to have a combination of strong horizontal integration and strong vertical integration
at the same time. When one of the two types of integration increases in strength, the other one will
automatically lose some of its strength.
In this research the importance to take into account the dynamics between both of the types of
integration, as argued for by Peters (2015) and Howlett & Del Rio (2015), is recognized. Indications of
how the dynamics between the two types of integration work are actively looked for and discussed where
possible, with the aim to identify leads for further research on the coordination dilemma. However, the
coordination dilemma is not fully tested. A single-N exploratory case study does not allow for
comparison, which means that it cannot be demonstrated that higher integration of one of the two types
results in low integration of the other. Therefore, the focus of this research is primarily to assess the
extent to which horizontal integration is achieved at district level and how this is influenced by
decentralisation. The effects of decentralisation are assessed by looking at the dynamics of vertical
coordination. To understand what is meant by coordination, the definition of Cejudo & Michel (2017)
is used. They define the ideal form of coordination to be a situation in which decision-makers come
together to define tasks, allocate responsibilities and share information to decide on how to implement
the policies and programs that strive to contribute to solving a complex problem. This research therefore
understands vertical coordination as all processes of information sharing, allocating responsibilities and
decision-making around implementation of nutrition policies and programs that involves some sort of
interaction between government levels. From this, the effects of decentralisation on the integration of
nutrition policy are deduced.
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2.1.3 Assessing policy integration
To assess the process of policy integration, the four policy integration dimensions described by Candel
& Biesbroek (2016) are used. This framework was chosen because it allows for assessment of the
process of policy integration and does not focus on the outcomes. It recognizes that a variety of levels
of integration is possible, and that integration is not always of a high level, but a situation can also lean
more towards disintegration. Also, it acknowledges that integration is not an organised step-by-step
process, but can take place in many different ways at the same time. As the current situation of the
research case is unknown, this recognition of fluidity of the process is needed to allow for identification
of any types of findings.
The framework is operationalised by using evidence from empirical case studies that discuss the process
of implementation of nutrition policy in a developing context. From this literature, multiple factors are
identified to influence the process of implementation of nutrition policy and are linked to the dimensions
of policy integration. In this way, these factors form a bridge between the real-life phenomena which
were observed in empirical studies and the theoretical dimensions of policy integration. It is deliberate
decided to only use literature that discusses nutrition policy implementation and no literature related to
Uganda yet. This step does not aim to formulate expectations or provide insight in the current situation
in Uganda. It purely serves to operationalise the dimensions in such a way that by using them it is
possible to identify observable phenomena relevant for the research question.
2.1.3.1 Frames
Frames is the first dimension through which policy integration is assessed. The definition given in
Candel & Biesbroek (2016) of a frame is how a particular problem is perceived within a given
governance system. In the context of this research, frames are used to assess how the nutrition issue is
understood by different stakeholders in Ntungamo district. This includes whether or not actors start from
a shared point of understanding of the causes and the policy approach used. This dimension does not
aim to assess whether the understanding is factually correct, but wants to find out whether understanding
among stakeholders is similar or there are diverging or contradictory views. Also, it wants to investigate
what is known about existing structures and how people believe these to be relevant in the light of the
policy being implemented. Policy integration is of a high level when there is shared understanding of
the multi-sectoral nature and causes of the problem and the existing institutional structure is enabling
for policy integration.
The first factor relevant for frames is the problem perception of the origin of malnutrition, which is
often related to wider political trends or dominating (political) narratives from certain sectors.
Depending on one’s perspective, the nutrition problem can be explained in various ways, using different
causes and solutions. Overall, this determines which barriers and facilitators are perceived to influence
16
(mal)nutrition and in relation to that what type of policy solutions are believed to create a positive impact
(Drimie et al., 2014; Harris & Drimie, 2012; Lapping et al., 2014). A shared frame of understanding of
the causes of malnutrition is important as it provides one starting point from which stakeholders start to
work. This increases the chance of consistency of policy instruments and the way in which actors go
about implementation. Related to this is the use of evidence by stakeholders. Stakeholders do not always
have equal access to available evidence, meaning that the starting point of those writing and
implementing policy is not necessarily the same (Harris & Drimie, 2012; Nisbett et al., 2014).
The second relevant factor are the existing (legal) documents and financial structures, which together
determine the existing institutional structure. The existing structure provides a frame of influence on the
context in which policy integration of nutrition policy takes place and can thus support or inhibit it.
Existing documents and structures include but are not limited to international guidelines, national policy
documents, (international) law or financial structures (Drimie et al., 2014; Lapping et al., 2014). Of
course, not all documents are taken into consideration. Only documents that are expected to be relevant
in the context of implementation of nutrition policy will be looked at in close detail to determine what
sort of influence they have on the implementation processes and thereby on policy integration.
2.1.3.2 Subsystems
The dimension subsystems captures which actors and institutions are involved in the governance system
of the cross-cutting policy problem and how they are organised. The governance system in this study
comprises all actors that are active at the district government level. The central level and sub-county
level are considered as two spheres of influence on the district governance system by means of vertical
coordination (see section 2.1.2). Actors are considered to be involved when they explicitly recognize
(mal)nutrition to be a problem in the district and are in some way working on interventions to address
it. Whether these interventions are successful is not relevant for assessing involvement. The actor-
networks are not limited to government, but also include non-governmental actors. Actors are
categorised as follows: government officials, politicians, NGOs, other CSOs and sub-county officials.
The reasoning behind this categorisation is further explained in section 3.3.1. Groups of actors that
cooperate in some way or work in the same organisational structure are in this study referred to as bodies.
Normally they would be referred to as subsystems and primarily include different policy sectors.
However, it is believed that this is too limited for this research, and therefore the broader understanding
of bodies is adapted. Identifying these bodies is relevant, because it provides information on the overall
activity on nutrition in the governance system. Not all bodies are equally involved or active, which also
makes the density of interactions among them important. The amount of interaction one body has with
other bodies gives an idea on the level of engagement of that body on nutrition (Candel & Biesbroek,
2016). Policy integration is of a high level when a multitude of, at least partially formal, bodies are
involved in the policy implementation process and there is a high density of interaction among them.
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There are three factors identified in the literature that provide insight in the level of a subsystems
engagement. The first one is commitment, which is needed from all stakeholders and at all government
levels to ensure mobilization of resources and to create spaces where coordinated action across sectors
can take place. Commitment will help to support implementation of policy and if necessary adjustment
of institutional structures, making conditions more favourable for policy integration (Acosta & Fanzo,
2012; Harris & Drimie, 2012; Kampman et al., 2017). Pelletier et al. (2012) define three levels of
commitment, namely: political attention, which means that issues of malnutrition are politically
recognized and explicitly addressed; political commitment, where allocation of the necessary resources
is ensured; and system-wide commitment, where not only politicians but also managers and implementers
commit to and act upon implementation of nutrition policy. This divide will be used to assess the
involvement of bodies in the governance system. Second, and closely related to commitment, is
leadership. To have leadership, highly placed officials or essential stakeholders need to actively support
the issue at hand, advocate for it and strive for commitment at the different levels. Leadership,
specifically of politicians, is essential in the process of designing, approving and implementing budgets,
legal instruments and policy plans. In this way it can help to create political commitment (Harris &
Drimie, 2012; Lapping et al., 2014; Nisbett et al., 2014).
Third is the existence of established coordination and communication bodies, which influences the
density of interactions. Whether or not a system has bodies with clearly defined roles and responsibilities
provides information about the position of central actors in the governance system. In addition to that,
the bodies can be compared to assess how they are organised and to what extent their tasks are similar
or different from each other (Acosta & Fanzo, 2012; Kennedy et al., 2015). Especially for complex
problems, such as nutrition, which involve many different stakeholders such bodies will help to connect
all these different actors and lower barriers of cooperation. This will stimulate further policy integration.
Fourth and closely related to this is the importance of authority for coordinating bodies so that they
are in a position to enforce collaboration. The existence of the bodies, including its functions, should be
recognized in the wider bureaucracy. Only with this recognition and authority, roles and responsibilities
can be fully executed across barriers of different sectors in a formal way. Next to existence and having
a certain level of authority, the functionality of the bodies also influences the density of the interactions.
2.1.3.3 Policy goals
The policy goals incorporated in policies and strategies adopted in a governance system should explicitly
address the complex problem. The extent to which policy goals express a truly integrated approach can
be seen from the range of policies that adopt nutrition as a goal. Also, the coherence between the policy
goals is important. In the case of weak coherence, the different goals and targets do include the topic but
are not aligned with one another. With strong policy coherence, different sectors jointly address the issue
18
and streamline their policy goals (Candel & Biesbroek, 2016). Policy integration is of a high level when
the range of policies which addresses nutrition is wide and there is strong coherence between the goals.
In the existing literature on nutrition policy, little evidence is found on what factors can influence the
dimension policy goals. Some remarks are made about that there should be agreement on expected
results and that it needs to be clear how these results are going to be monitored (Harris & Drimie, 2012;
Warren & Frongillo, 2017). Policy goals should also be coherent, in the sense that they are aligned and
integrated with other development plans and goals. Ensuring an explicit link with the overall
development plans of a country or region will help to have people see how nutrition can contribute to
overall development (Meerman, 2008). Both of these stimulate policy integration, as they ensure that
different stakeholders work towards a shared and overarching goal.
2.1.3.4 Policy instruments
This dimension includes all policy instruments within a governance system that have been suggested to
be used to improve the nutrition situation. A distinction is made between substantive and procedural
policy instruments. Substantive policy instruments directly affects public service provision. Procedural
instruments affects this more indirectly through manipulating the policy process. Three indicators are
identified by Candel & Biesbroek (2016) to measure the level of policy integration for policy
instruments. First is the range of instruments, either procedural or substantive, deployed by all
subsystems. Second is whether there are any procedural instruments in place that support coordination
or communication bodies which are looked at under subsystems. Third, and last, is the consistency of
the instrument mix that has been developed over time across the governance system (Candel &
Biesbroek, 2016). Policy integration is of a high level when there is a wide range of different types of
policy instruments that together forms a consistent whole and includes procedural instruments that
support a coordination and communication structure.
The literature on nutrition policy focuses predominantly on capacities that limit the implementation of
substantive policy instruments. There is often a lack of human resources. Few institutions in
developing countries offer nutrition programs and in other curricula nutrition is not given enough
attention. Therefore, there is a shortage of people with sufficient knowledge and training on nutrition.
In some cases it was also found that staff turnover is high, which affects the continuity of service delivery
(Drimie et al., 2014; Harris & Drimie, 2012; Lapping et al., 2014; Meerman, 2008; Warren & Frongillo,
2017). An issue closely related to human capacities is the importance of understanding of the local
context by those working on policy implementation. It was found that knowledge on the local reality is
often lacking and there is not enough familiarity with the on-the-ground situation. Without this
familiarity, people might not be able to implement policy instruments in such a way that it makes sense
in the local context (Lapping et al., 2014; Nisbett et al., 2014). Another issue related to capacity are
19
financial issues. Budgets available for nutrition are rarely ever sufficient. Also, budget transferral to
implementing institutions or lower level governments was in several cases delayed. Even when there
are policy instruments in place to address nutrition problems, if capacity to carry out interventions is
insufficient, this affects the level of policy integration. Instruments cannot be designed or implemented
properly, which decreases the work done on the issue at stake. In the literature, no information was
found on procedural influence that can possibly influence policy integration or on the consistency of
policy instruments that can be used for nutrition. Therefore, no factors of possible influence are
identified for these aspects of policy instruments.
2.2 Decentralisation
2.2.1 Decentralisation defined
Decentralisation refers to the transfer of political, fiscal and administrative power and responsibility
from the central government to lower level governments (Fessha & Kirkby, 2008; Litvack, Ahmad &
Bird, 1998; Muhumuza, 2008). The exact degree to which autonomy is transferred to these lower levels
depends on the type of decentralised system being implemented. The most far-reaching type is
devolution, where local units have a significant amount of autonomy on the fiscal, administrative and
political aspect. Local government units have their own elections and there is little oversight of the
central government, meaning the central government has transferred its power. For devolution to
function, it is important that the power-transfer takes place in all of the three sectors mentioned above
(Fessha & Kirkby, 2008; Francis & James, 2003; Litvack, Ahmad & Bird, 1998; Muriisa, 2008).
Uganda has a devolved decentralised governance system, which is the most far-reaching type of
decentralisation. Its governance structure exists of the central level government and five lower
government levels, as can be seen in figure 2. The governance structures in rural and urban settings
differ slightly from each other, but as this research is conducted in a rural setting only that structure is
relevant. In a rural setting the lowest level is the village, which is followed by the parish, the sub-county,
the council and last the district. Of these five levels, only the district and the sub-county have political
bodies. The other three levels have purely administrative functions (Fessha & Kirkby, 2008; Green,
2015; Kakumba, 2010; Ojambo, 2012).
20
Figure 2: The Local Government Structure in Uganda (adopted from Turyahabwe et al., 2006)
As this research focuses primarily on the district level, it is relevant to know some more about the
organisation and structures at district level. The district has the right to exercise all political and
executive powers and thereby has a wide range of tasks and responsibilities. It provides services, ensures
implementation of government policy, plans for the district and enacts legal structures. The technical
head in the district is the Chief Administrative Officer (CAO), who also chairs the District Technical
Planning Committee, which is the main bureaucratic committee in the district. This committee works
on development plans, discusses progress of program implementation and supervises progress. It is
composed of the heads of the sectoral departments, who are responsible for the technical work of their
individual departments. As the district is responsible for the provision of a wide variety of public
services it has several departments to support this. There is no prescribed list of departments that each
district should have, as the CAO has the mandate to determine the local governance structure in line
with the Local Government Act of 1997. However, some of the most common ones are education, works
and technical services, production, health, management support services, finance and planning and
community based services. The elected political head of the district is the chairperson, who also heads
the district council. The district council debates budgets, policy plans and bylaws, for which the technical
input is provided by the Technical Planning Committee. The council exists of politicians chosen by
electoral constituencies and sits for a period of four years (Onyach-Olaa, 2003; Raussen, Ebong &
Musiime, 2001; Steiner, 2008).
When in a decentralised governance system multiple government units are split up into two or more new
units in a short period of time this is referred to as administrative unit proliferation. If this happens,
structures need to adopt rapidly, which can have a negative effect on the fiscal situation and
21
administrative and human capacity of lower government units. With increasingly large numbers of
smaller units, bargaining power and capacity of each individual unit goes down. The relative amount of
power one unit has in relation to the central government decreases, making it more difficult to influence
processes such as setting priorities for budgets or influencing development plans. This fragmentation of
power results in the opposite of what decentralisation should create. Rather than having strong an
autonomous lower government units, it leads to weak and dependent units. It is therefore also referred
to as recentralization, as the central government tries to reassert control (Lewis, 2014; Wunsch, 2001).
At this point, Uganda has the highest number of local government units of all countries in the world. In
2017 there were 121 districts, which is three times more than in the 1990s and indicates a case of
administrative unit proliferation (Green, 2015; Ministry of Local Government). Evidence that this trend
has led to the argued benefit of improved service delivery is lacking. On the contrary, the number of
districts that has met the minimum performance standards set by the Ugandan government has decreased
over time, indicating worsening service delivery (Green, 2015). New districts have to share resources
with the mother district but at the same time, investments in new staff and built infrastructure have to
be made. Also administrative transitions, such as transfer of relevant documents, is often problematic.
The amount of resources available decreases, which makes good public service delivery more
challenging. These things can all be considered negative effects of administrative unit proliferation
(Manyak & Katono, 2010; Lewis, 2014).
2.2.2 The expected effects of decentralisation on horizontal policy integration
The relation between decentralisation and policy integration is operationalised based on literature that
discusses the relation between the two concepts. The only literature that has addressed this relation so
far is literature on Environmental Policy Integration (EPI). An exception to this is the article by McIntyre
& Klugman (2003), which discusses the integration of health services in a decentralised system. All of
this research demonstrates that the characteristics of decentralisation have made successful
implementation of EPI policies more difficult. This is in line with the suggested relation between
decentralisation and policy integration of nutrition policy in the introduction. Therefore, EPI literature
is a good source of information to operationalise decentralisation in the context of this research. Factors
specific to decentralisation that have shown to influence policy integration are identified and some first
expectations on how decentralisation can influence policy integration are formulated. After that,
information from both academic and grey literature is provided on the structure and functionality of the
decentralised governance system in Uganda. The last step in operationalising decentralisation is to
describe what will be looked at specifically in this research to determine whether the expectations hold.
22
2.2.2.1 Clear coordination and communication
The autonomy that regional governments should enjoy in decentralised systems is in reality often only
partially or conditionally transferred (Fessha & Kirkby, 2008). Because of this partial transfer of
autonomy, confusion arises over the exact mandate of lower level governments and the tasks for which
each level is responsible. It was found in previous research that clear communication and coordination
between levels about the roles and responsibilities of actors and bodies at each level is necessary.
Mandates might otherwise become too vague, too broad or assigned to none or multiple actors or bodies.
To ensure clear mandates, things need to be discussed explicitly between different levels. Otherwise the
danger of confusion, duplication or no action at all is significant (Casado-Asensio & Steurer, 2014;
Lockwood et al., 2009; McIntyre & Klugman, 2003; Steurer & Clar, 2015). It is therefore expected that
vertical communication between decentralised government levels can be a barrier in creating a clear
mandate on coordination responsibilities for each horizontal government level.
In the Uganda Nutrition Action Plan (UNAP) the structure of the District Nutrition Coordination
Committee (DNCC) is outlined. This is a coordinating body that according to the central level policy in
Uganda each district level should have. A DNCC should exist of 10-15 relevant stakeholders from
different Non-Governmental and Civil Society Organisations (NGOs and CSOs) and at least the
following government departments: planning, health, production, works & technical services (water),
education, community development, trade & industry and local economic development. The roles and
responsibilities of this committee are multiple but they are mainly concerned with ensuring effective
planning and budgeting for nutrition programs, coordinating the different partnerships the district has
with implementers working on nutrition and monitoring the ongoing activities. For planning and
budgeting for nutrition programs, the DNCC should be in close contact with the Technical Planning
Committee. In this way, they should ensure that input on nutrition is used in the further process of policy-
making (Government of Uganda, 2011; “Message for District …”, 2011; “Multi-Sectoral Nutrition
Coordination”, 2017).
The question that needs to be looked at to assess this expectation is whether these instructions in the
UNAP have also reached the district level and whether all actors are familiar with the DNCC’s task
description. For this to have happened, clear communication between the central level and the district
level needs to have taken place as to ensure that the mandate of the DNCC is widely understood and the
structure itself is in place. This will be assessed by learning more about the process of how and by whom
the DNCC was set up, whether its member composition follows the guidelines and if responsibilities
and tasks are clearly defined. Next to that, it will also be considered whether there are any other
coordinating structures that might have an influence on the implementation of nutrition policy and how
they relate to the DNCC. This creates a better understanding of whether mandates are also differentiated
enough and if this is in any way influenced by decentralised structures. In an ideal situation, good
23
communication on these things helps to support horizontal integration, as it is more likely that there
exists a functioning body with well-defined roles and responsibilities that streamlines implementation
of nutrition policy by different actors at district level. This increases the level of integration primarily
for the dimension sub-systems.
2.2.2.2 Human resources
Another issue that is a typical problem in a decentralised system is the lack of human resources. Because
of the many responsibilities each local government level has in a decentralised system, there is high
demand for qualified people. However, these are not always available in large enough numbers. Well-
trained staff with the right capacities are scarce and as a result, local government officials are regularly
un(der)educated and not able to carry out their tasks as expected. One of the main argued benefits of
decentralisation, namely improved service delivery that aligns better with the wishes of the local
population, is lost without having enough human capacity (Charbit, 2011; Lewis, 2011). Based on this
it is expected that decentralisation has a negative influence on the availability of human resources to
ensure successful horizontal policy integration of nutrition policy at lower government level.
The lack of human capacity is also a problem in Uganda. There are often simply too few people available
that are sufficiently qualified for certain jobs. This is especially problematic taking into consideration
that in Uganda districts are responsible for public services such as health care provision and education
and at the same time administrative unit proliferation is ongoing. With the creation of additional lower
government units more human resources are required, putting further pressure on the system. So far, the
this has affected service delivery negatively, as the number of districts that has met the minimum
performance standards set by the Ugandan government has decreased over time. One of the underlying
issues is that resources, including human resources, need to be shared among an ever increasing number
of districts (Green, 2015; Lewis, 2011; Manyak & Katono, 2010)
To assess the influence of human resources on policy integration various aspects are looked at. It is
assessed how many people are actively working on nutrition, whether it is their main priority and if they
feel they can carry out tasks and responsibilities in relation to nutrition. Specific attention is paid to
whether there is enough human capacity to work across boundaries and invest time in setting up an
integrated approach. How people perceive their own and other’s level of knowledge is also taken into
account, to get a better idea of whether people are sufficiently qualified, both in relation to nutrition and
in understanding policy integration. This research does not assess the level of service delivery of
nutrition services itself, and therefore everything related to human resources is tested by people’s
perceptions. The actual quality of service delivery is not evaluated. An adequate level of human
resources positively influence policy integration across all dimensions but most specifically policy
24
instruments and sub-systems. People with sufficient capacities are necessary in all different parts of the
governance system to implement policy instruments needed for a high level of policy integration.
2.2.2.3 Consultation of regional actors
Previous research has shown that consultation of regional actors in national level decision-making
processes happens infrequently or not at all in decentralised systems. Inclusion of those that are supposed
to implement the policy at lower government levels is essential to build understanding of the policy and
create motivation to work on it. To create such a structure, policy making processes would have to be
structured more bottom-up rather than top-down, so that opinions of all those involved at different levels
can be included (Casado-Asensio & Steurer, 2014; Howlett, Vince & del Río, 2017; Lockwood et al.,
2009; McIntyre & Klugman, 2003; Steurer & Clar, 2015). It is therefore expected that difficult bottom-
up consultation between government levels in a decentralised system has a negative influence on the
policy-design and implementation processes.
In Uganda, the District Development Plans (DDPs) should be created in a bottom-up manner, meaning
that they should include input from lower government levels. This input should be gathered from the
lowest level, the village level, and with input from all consecutive levels serve as the basis for the DDP.
Ideally, this leads to a situation where service delivery matches people’s needs and demands that they
have been able to formulate in the process of policy design. However, in practice this has been difficult.
Due to issues such as lack of knowledge and organisational structure, the DDPs rarely incorporate lower
level input, indicating that at this point the consultation structures are not well-functioning (Azfar,
Livingston & Meagher, 2006; Kakumba, 2010; Ojambo, 2012).
This research does not focus on the policy design process but rather on policy implementation.
Therefore, the focus is widened from consultation for policy design to consultation of different
government levels throughout the process of implementation. To get an idea of this it will be investigated
whether actors feel involved and heard in the process of implementation. Also, a closer look will be
taken at whether local policy documents that discuss nutrition are believed to match with local reality
of the nutrition situation and whether relevant actors are included in the design and implementation of
these documents. Good consultation makes it likely that the process of policy integration will go more
smoothly, as involvement of a wide variety of actors and their opinions will help to work more
inclusively across sectors. This will especially improve the level of policy integration for goals and
frames, as there is a shared understanding of the current problem and what goals should be strived for
to improve the issue.
25
2.2.2.4 Financial structures
Lastly, financial structures have often proven to be problematic for the implementation of integrated
policies in decentralised system. Local government units often struggle with highly centralised
budgeting processes, with much upward accountability. Budgets from the central are in many cases still
conditioned. This undermines local decision-making, as without budget, one cannot implement its
decisions. Raising local revenue that lower government levels can spend freely is especially challenging
in poor and rural areas. Revenue sources are not large enough, meaning that the lower government units
continue to be dependent upon the central government for funding or end up with a budget shortage
(Charbit, 2011; Dickovick & Riedl, 2010; Francis & James, 2003; Litvack, Ahmad & Bird, 1998;
Lockwood et al., 2009; McIntyre & Klugman, 2003; Wunsch, 2001). It is therefore expected that
decentralisation worsens the financial situation of lower government levels and inhibits a policy
integration approach.
The description above is a perfect fit with Uganda’s current financial system. The central government
transfers three types of grants to lower level governments, namely the unconditional, the conditional and
the equalization grant. Making up about 90% of these transfers, and thus most important, are the
conditional grants, which are earmarked by the central government for specific activities. The amount
of local revenue raised by districts is low and over the years sources out of which this local revenue can
exist have decreased. Therefore 95% of the district budgets exists of conditional government transfers.
Because of this structure, it becomes almost impossible for the district government to execute plans
based on existing priorities (Green, 2015; Lewis, 2014; Manyak & Katono, 2012; Muhumuza, 2008;
Ojambo, 2012).
To understand how the finances of the lower government levels is influenced by the decentralisation,
both the financial structure and its (in)dependence in relation to the central level are researched. This is
done by looking at the composition and origin of the district budget, whether this budget is sufficient to
finance policy integration of nutrition. Also the freedom that lower government levels have to make
decisions about how to spend these resources is taken into account, as its follows from the definition of
decentralisation that lower government levels should also have fiscal autonomy. Having autonomy in
spending resources and having access to sufficient resources make it easier to create an enabling
environment for policy integration, in which working across sectors can be financially supported.
26
2.3 Concluding Remarks
In this chapter two steps were taken to operationalise the research question. The first step was to
operationalise the concept policy integration using literature that studied the process of implementation
of any type of nutrition policy in developing settings. Relevant factors were extracted that have a proven
to influence the process of implementation and these were connected to each of the four policy
integration dimensions. In this way the level of horizontal policy integration in Ntungamo district can
be assessed. The following relevant factors for each of the dimensions were found:
Figure 3: Visualisation of the operationalisation of the Policy Integration dimensions
Important to note is that, following the definition of policy integration as provided in section 2.1.1, the
focus of this research is process-oriented and not outcome oriented. Assessing the level of policy
integration therefore done by looking at the process of implementation of nutrition policy. The outcome,
which in this case is the quality of service delivery of nutrition services and taking it one step further,
the nutrition status of Ntungamo’s population, is not relevant for this research.
In the second step some expected effects of decentralisation on policy integration have been formulated
by making use of literature on Environmental Policy Integration, supported by literature on
decentralisation in Uganda. Deduced from the concept of coordination, the focus is on assessing the
influence different government levels have on one another and the interaction between these levels. As
the district is the focus of this research, the only processes of interaction and influence that are
considered are those that the district is a part of. Using the findings generated by this step, the effect of
decentralisation on policy integration at district level can be assessed:
27
Figure 4: Visualisation of the operationalisation decentralisation in relation to policy integration
The combined operationalisation of policy integration and decentralisation forms the basis for data
collection and data analysis. The data collected will be analysed in two steps. First, the level of policy
integration is determined by analysing results for each of the four dimensions. After that, the evidence
found for the expectations is discussed. Both the factors identified and expectations formulated in the
previous sections are therefore not exhaustive, but merely serve as a starting point for the analysis. It is
likely that the empirical evidence will add new information as well as dismiss or confirm parts of the
framework.
28
CHAPTER 3: RESEARCH DESIGN AND METHODOLOGY
3.1 Ntungamo District as a Case Study
Ntungamo District is in the Southwest of Uganda, a region that is considered to be the country’s food
basket, but at the same time struggles with malnutrition rates as high as or above the national average
(FAO, 2010; USAID, 2018). In the Uganda Demographic and Health Survey (UDHS) of 2016, in which
Ntungamo is part of the Ankole region, the stunting levels in this region are 29.3%. This is similar to
the national average (Uganda Bureau of Statistics & ICF, 2017, p. 31). However, in the UDHS of 2011,
Ntungamo is categorised as part of the Southwest in which stunting levels were at 41.7%, the third
highest percentage of all regions in the country (Uganda Bureau of Statistics & ICF International Inc.,
2012, p. 143). The only data publicly available for Ntungamo district are those in its District
Development Plan (DDP) published in 2015. There the average level of stunting is estimated to be 32%,
which is above the national average. This, in combination with the fact that Ntungamo is considered to
be a part of Uganda’s food basket, demonstrates a problematic nutrition situation.
Next to its worrying nutrition situation, Ntungamo is also selected because of its stable governance
structure. Since 1993, the district structure itself has not been exposed to administrative unit proliferation
(Government of Uganda & Ntungamo District). This makes it an easier research object, because chances
are higher that people and structures and in place in Ntungamo compared to in a district that has just
undergone administrative unit proliferation. At the same time, within the district new sub-counties and
town-councils have been formed or the rearrangement processes are still ongoing. These dynamics at
sub-county level could provide some interesting perspectives on administrative unit proliferation and
their influence on governance structures. Practical reasons also played a role in the choice for Ntungamo.
Local contacts were available, the district has good infrastructure and is safe and easily accessible. Also,
the certainty that there were structures in place for the implementation of nutrition policy meant that it
would be possible to gather enough data of good quality.
3.2 Criteria for selecting the sub-counties in Ntungamo District
By including another level of lower government in this research, the dynamics of vertical coordination
can be assessed in relation to horizontal policy integration, as to provide information on the coordination
dilemma. The most logical option is to include the sub-counties, as the district and the sub-county are
two consecutive lower government levels. To ensure that the inclusion of sub-counties provides as much
information as possible, two criteria have been chosen based on which the sub-county selection is made.
It is expected that these criteria are relevant in relation to how nutrition policy is integrated in the sub-
29
county and might in that way influence the dynamics of vertical coordination between the sub-counties
and the district. This can help to provide important leads for the coordination dilemma.
The selection focussed specifically on sub-counties, of which there are fifteen in Ntungamo. Town
councils, of which Ntungamo has three, were excluded because they follow a slightly different
decentralisation structures compared to the rural structure. Also, many of the town councils in Ntungamo
are relatively new and might therefore not yield as much relevant information because structures are not
in place yet. The two selection criteria for the sub-counties are the following:
• The stunting level in the sub-county: this is relevant in the context of nutrition and can help to
gain insight on whether a relatively poorer or better nutrition situation is related to certain trends
in the process of policy implementation of nutrition policy.
• The number of NGOs working on nutrition in the sub-county: NGO activity on nutrition could
potentially influence the governance structures, for example through their support in building
government capacity. Different numbers of active NGOs could give more information on
whether the presence of NGOs influences dynamics of policy integration.
These two variables are used as two axes in a matrix, based on which the most extreme case (sub-county)
of each of the four boxes in the matrix is selected. This ensures that there is a sample with different
characteristics, which makes it possible to draw preliminary conclusions on whether the variables have
any influence on vertical coordination or the functionality of policy integration at sub-county level.
3.2.1 Level of stunting per sub-county
The data for level of stunting per sub-county, registered separately for boys and girls, was retrieved from
the Ntungamo District Development Plan 2016. Using the percentages for boys and girls the average
was calculated and based on this the sub-counties were ranked. In case the average was the same for
two sub-counties, they were given the same rank and the subsequent number was skipped.
30
Table 1
Level of Stunting in the sub-counties of Ntungamo District
Sub county
Girls
(% stunting)*
Boys
(% stunting)*
Average
(% stunting)
Rank
(#)
Bwongyera 26 33 29.5 10
Ihunga 35 36 35.5 5
Itojo 31 54 42.5 1
Kayonza 31 54 42.5 1
Kibatsi 24 38 31.0 9
Ngoma 25 26 25.5 13
Ntungamo 20 27 23.5 15
Nyabihoko 26 46 36.0 3
Nyakyera 20 31 25.5 13
Rubaare 25 40 32.5 8
Rugarama 23 36 29.5 10
Ruhaama 32 35 33.5 7
Rukoni east 30 41 35.5 5
Rukoni west 24 31 27.5 12
Rweikiniro 37 35 36.0 3
Average 27.3 37.5 32.4 n.a.
Note: The original source of the data is the Ntungamo District Development Plan 2016
3.2.2 Number of NGOs active on nutrition in each sub-county
Not all NGOs operate in each sub-county when they are active in Ntungamo district. The information
of which NGOs is active in where exactly was not ready available, so was gathered from different
sources and then combined. This led to the overview in table 2.
Table 2
Number of NGOs active per sub-county (before interviews)
Project →
Sub county↓
TPO USAID-
RHITES
SASA
KAWA
Global
SNV
TIDE
project
USAID
–
Marie
Stopes
UNICEF Red
Cross
Apro
cel
UMFSNP USAID –
SPRING
(Finishe
d 2015)
Total #
implementa
tion
activities
Bwongyera X X X 3
Ihunga X X X 3
Itojo X 1
Kayonza X 1
Kibatsi X X 2
Ngoma X 1
Ntungamo X 1
Nyabihoko X 1
Nyakyera 0
Rubaare X X 2
Rugarama 0
Ruhaama 0
Rukoni east 0
Rukoni west 0
Rweikiniro X X 2
Additional
remarks
Also
Rubaare
TC
Entire
district
Entire
district
Health
units
Entire
district
Entire
district
Entire
district
Finished
in 2015
Note: Based on information in Ntungamo MSNAP Midterm review report, information from the district statistician
and information from the Assistant Chief Administration Officer (CAO)
31
3.2.3 Sub-county selection matrix
Combining these two variables, the stunting levels and the number of NGOs active in each sub-county,
the following matrix was composed.
Figure 5: Sub-county selection matrix before interviews
Based on this matrix, the following sub-counties were chosen for the interviews :
• High stunting, extra NGO nutrition activities: Ihunga. It has three extra nutrition activities,
Sasakawa Global, Aprocel and USAID SPRING, whereas the others in this box only have two.
It also has high stunting levels.
• High stunting, no extra NGO nutrition activities: Kayonza. It has the highest stunting levels of
all sub-counties. There is only one extra nutrition activity. Although Itojo, with the
implementation of the USAID SPRING project can provide interesting insights, it was not
selected because a finished project is more likely to have significant impact. The project in
Kayonza is less likely to have had such an impact at this point.
• Low stunting, extra NGO nutrition activities: Bwongyera. There are three extra nutrition
activities, of which the USAID SPRING project is completed. Also, there is no other sub-county
that meets the requirements for this box.
• Low stunting, no extra NGO nutrition activities: Nyakyera. It has no extra nutrition activities
and the second-lowest levels of stunting. The difference in the level of stunting with Ntungamo
is very small, so no extra nutrition activities makes for the most interesting case.
However, during the interviews it became apparent that not all information in table 2 was correct or
complete. As the interviews were done simultaneously with the sub-county selection, this was not
corrected for anymore. There were two major changes. Firstly, Aprocel and TPO are two different NGOs
but they implement the same project. Their project is active in nine sub-counties, but the three sub-
counties they focus on are Ihunga, Kibatsi and Rubaare. Secondly, Sasakawa is or was active not in
three but in nine sub-counties. Next to that, it was not possible to confirm whether USAID Marie Stopes
32
and UNICEF are indeed working in the district on nutrition. However, as there is no indication that these
projects are only active in specific sub-counties they do not influence the selection. In table 3 the new
project implementation overview per sub-county can be seen.
Table 3
Number of NGOs active per sub-county (after interviews)
Project →
Sub county↓
TPO &
Aprocel
USAID-
RHITES
SASA
KAWA
Global
SNV
TIDE
project
USAID –
Marie
Stopes
UNICEF Red
Cross
UMFSNP USAID –
SPRING
(Finished
2015)
Total #
implemen-
tation
activities
Bwongyera X X X 3
Ihunga X X 2
Itojo X X 2
Kayonza X 1
Kibatsi X 1
Ngoma X 1
Ntungamo X X 2
Nyabihoko X 1
Nyakyera X 1
Rubaare X 1
Rugarama 0
Ruhaama 0
Rukoni east X 1
Rukoni west 0
Rweikiniro X X 2
Additional
remarks
Also
Rubaare
TC
Entire
district
Entire
district
Health
units
Entire
district
Entire
district
Entire
district
Finished
in 2015
Including this new information into the matrix, the position of various sub-counties changes:
Figure 6: Sub-county selection matrix after interviews
33
Based on this new matrix, the selection would have differed for some of the boxes. Not Ihunga but Itojo
would have been selected, because it has the highest stunting levels and there is no difference in the
number of NGO activities. Kayonza or Ruhaama would have been selected, but Kayonza remains a
relevant case for this box, because of its high stunting levels. Instead of Bwongyera, Ntungamo could
have been an interesting addition to the sample, because its stunting levels are the lowest of all sub-
counties. For the last box, Rugarama or Rukoni West are the most logical choices in hindsight.
3.3 Data Collection Methods
Interviews and document collection were used to gather data. All data was collected in August and
September 2018 and is in English. The collected data is analysed by coding the interviews and analysis
of the documents. The information retrieved from the two different sources is compared where possible,
so that a rich picture of data can be provided.
3.3.1 The Interviews
3.3.1.1 Categorisation and selection of respondents
The respondents are categorised into five different stakeholder categories: district bureaucrats, NGOs,
district politicians, sub-county and others. This categorisation is chosen because it follows the formal
governance structures. These distinctions are relevant because it allows for the opinion of different
stakeholder groups to be compared and possible similarities and differences to be identified. Furthers
specification is not made, as this can harm the confidentiality of the respondents (see section 3.5.3). The
codes under which each of the respondents is listed in appendix 1 are also used for referencing in the
results section.
The DNCC was used as a starting point to select actors that were relevant to interview. It was tried to
identify all DNCC members and schedule interviews with as many of them as possible. Later on in the
research, actors that were not part of the DNCC, but were expected to be aware of or involved with
nutrition in the district were approached. This made it possible to also assess the wider dynamics of
policy integration of nutrition policy in the district.
In total 26 interviews were conducted. Of these, 21 interviews were conducted with people working on
nutrition at district level, either for an NGO or for the district. The split between NGO and government
workers was almost equal, with a few more district bureaucrats. From the government workers the
majority were bureaucrats. Only three politicians were interviewed. Expanding the range of politicians
would have been interesting, but it was difficult to identify individuals who were relevant to talk to.
Further reflection on the relevance of including more politicians can be found section 3.5.1. Five
interviews were conducted at sub-county level, all with government workers. Three out of the five sub-
34
county interviews were small focus groups, the other two individual conversations with people from the
same sub-county. The interviews ranged from 30 to 65 minutes, with an average duration of 50 minutes.
For the list of all interviews conducted see appendix 1.
3.3.1.2 The interview structure
The interviews were conducted in a semi-structured way with the aim of exploring and understanding
the topic, supporting the exploratory research approach (Cohen, 2000, p. 270). The interview script
served as a point of reference to ensure all relevant topics were covered, but was not strictly followed.
If interesting topics were brought up, the interviewer deviated from the original script. The interview
script was adjusted depending on what type of actor was interviewed. Distinctions were made between
district and sub-county level, government staff and NGO staff and whether an actor was part of the
DNCC or not.
In the interview script questions related to all four dimensions of policy integration as well as
decentralisation were included. The factors identified to be of possible influence on the dimensions of
policy integration and the expectations formulated for decentralisation are all extracted from empirical
studies. Therefore they are much more closely related to phenomena that are observable in real-life
situations. This makes them suitable as a starting point for formulating interview questions that are
understandable and answerable for participants of the research. For example, for the dimension
subsystems of policy integration the connection between the three layers is as follows:
Figure 7: Schematic visualization of an example of the connection between data collection methods and
the theoretical concepts
In many cases, decentralisation is not asked about directly because this could steer the responses to the
question. In this example, decentralisation is included by asking a question on the communication and
information sharing between different actors, which relates to one of the expectations. Depending on
35
the answer, influences of decentralisation can directly be identified or follow-up questions more specific
to communication in a decentralised system can be asked. In this way, the interview questions allow for
assessing the effects of decentralisation on policy integration.
In addition to the questions on policy integration and decentralisation questions are also asked about the
District Nutrition Coordination Committee (DNCC). These questions were phrased with help of
information on the DNCC in literature sources (as also briefly described in section 2.2.2.1). Altogether,
this interview script allows to collect relevant information for the two central concepts in this research
as well as information on existing structures in the district. The complete interview script can be found
in appendix 2.
At the beginning of each interview informed consent was acquired from the participant. The key points
of the informed consent form; the aim of the reason, confidentiality for the respondent, sharing of data
and permission of recording the interview, were explained to the respondent. After that, time was given
to them to read the full form. Confidentiality was guaranteed by ensuring that no statements made can
be traced back to one single actor. Important to realize is that this is different from anonymity, because
respondents answers are not recorded anonymously due to the fact that they were conducted face-to-
face (Kumar, 2014, p. 284-286).
3.4.2 Relevant Documents
Relevant documents were gathered during the entire duration of field work. Initially, the focus was on
official documents from the district that could include nutrition, such as the District Nutrition Action
Plan (DNAP) and the District Development Plans (DDPs). It turned out that a wider range of documents
with information on the DNCC, such as minute meetings and attendance, was available as well. It was
also attempted to acquire minutes of the District Council and relevant sub-committees, to be able to
assess how nutrition was discussed. The full list of documents acquired during the fieldwork can be
found in appendix 3.
3.4 Data Analysis
3.4.1 Processing and coding interview data
All interviews were recorded and fully transcribed, with the exception of the introductions and things
that were not related to the research at all (e.g. personal information). The interviews were coded to
extract all necessary information to answer the research question, for which Atlas.ti (version 7.5.18) was
used. Before coding was started a first set of codes was put into Atlas.ti, which were all related to the
factors linked with policy integration or decentralisation, as discussed in chapter 2. It was assumed that
by connecting specific quotations to codes and then the codes to the factors and thereby to the theoretical
36
concepts, all relevant information would be extracted from the interviews. In a schematic representation,
this looks as follows:
Figure 8: Schematic visualization of steps in the data analysis process
In the process of coding the interviews new codes were added if multiple respondents discussed that
topic. Some codes were split up and further specified if a too large variety of quotations would fall under
one code. After having finished coding the interviews, this resulted in a total of around 70 codes. As a
second step codes were grouped into families and new codes were connected to the different factors.
Some codes were merged when their content was overlapping too much, which reduced the total number
of codes to around 50. The full list of codes can be found in appendix 4. This improved data file with in
total 50 different codes served as the basis for the results.
3.4.2 Processing document data
The relevant documents gathered were not entered in Atlas.ti but analysed manually. It was deliberately
decided not to use coding, because large parts of most documents were irrelevant. Overview documents
were made which summarized the relevant findings of the documents, in which only information in
relation to the four dimensions or to decentralisation was extracted. In the analysis, this information
served as a means of triangulation so that trends found in interview data can be verified.
37
3.5 Reflections on the Research Design and Methodology
3.5.1 Credibility, transferability and dependability
The terms validity and reliability originate from quantitative research. In the Handbook of Qualitative
Research, edited by Denzin and Lincoln (1994), new terms to assess trustworthiness of qualitative
research, based on the principles of validity and reliability, were developed (Kumar, 2014, p. 184-185).
These are used to discuss the value of the data gathered in this research.
Credibility, the alternative for internal validity, assesses whether the data are credible or believable from
the perspective of the research participant. Interviews as a main method helps to establish credibility,
because interview data are primary data provided by the participants themselves. However, two possible
obstacles to credibility remain. Firstly, it is difficult to judge whether people answer questions honestly.
This research topic is not very sensitive, which increases the chance that people will reply to questions
honestly. Only when it came to topics such as (political) leadership, there were a few respondents that
decided not to answer a question. Whether people have given favourable rather than honest answers
cannot be said with certainty. In some cases people did make the assumption that I was able to provide
support to the district. Although I always explained that my sole purpose of the interview was collecting
data for research, this misunderstanding could have influenced people’s answers. Secondly, whether the
respondent answers the question asked and whether this response is interpreted correctly in the analysis
can never be guaranteed. The language barrier and cultural differences played a role in this.
Three things in the research have contributed to a good level of credibility. Firstly, the policy documents
gathered during the fieldwork allow for verification of answers given by respondents. Secondly,
following the same structure for all interviews makes it possible to identify trends and deviating answers.
Thirdly, there is a wide variety of respondents that together make up a large and diverse sample. By
including all the different perspectives, a complete picture is formed and deviating answers are more
easily spotted.
Transferability, or in quantitative research external validity, assesses the extent to which findings can be
generalized or transferred to other contexts. The results of a qualitative exploratory case study are
always, at least to some extent, specific to the context. However, by incorporating the findings into a
conceptual framework they can be contrasted with the findings of other studies. Trends can be
confirmed, unique findings identified and future research points formulated. Using a conceptual
framework thus makes it easier to assess the extent to which findings can be generalized.
However, repeating this research methodology in a different district is unlikely to lead to similar results.
This can be explained by looking at the reasons why the district was selected for this research. Next to
issues of malnutrition, which are common in district across Uganda, Ntungamo was also selected based
on its stable governance structure and the knowledge that there was enough activity on nutrition in the
38
district to gather a sufficient amount of relevant data to conduct an in-depth analysis using the conceptual
framework. In this sense, this district can be considered as an ideal research case, because it allows for
relevant conclusions to be drawn. It is very well likely that in many other districts there is not nearly as
much activity on nutrition. Although such a finding is also provides relevant information on the process
of policy integration of nutrition policy in Uganda, it would not be possible to conduct an analysis of
the data in a similarly detailed way. The non-random choice of Ntungamo district therefore limits the
transferability of this research.
Dependability, designed based on the principle of reliability, concerns whether research can be repeated
with obtaining the same results. Similar to transferability this is difficult for qualitative exploratory
research. The procedures of the research can be repeated, but the chance that this results in the same
findings in Ntungamo district is nihil. Policy implementation is constantly in motion. Also, people
change positions and the pool of respondents is therefore different. It could even be argued that one
should not want the same results when repeating a qualitative case study, because that means that there
has been no evolution of policy implementation at all.
In short, the procedures of this research are clearly documented and can be repeated or used for other
case study research. The findings are unique to this case and it is highly unlikely to find the same results
when repeating this research, especially in districts where there is significantly less activity on nutrition.
Rather, these results should serve as input for further theory building. The integration of evidence from
other cases studies in the conceptual framework is helpful for this.
3.5.2 Ethics
This research is connected to the PhD project titled “Integrated nutrition strategies beyond paper
realities: the case of Uganda”. This project was approved by the Mildmay Uganda Research Ethics
Committee under the reference number 0106-2017 and by the Uganda National Council for Science and
Technology under the reference SS83ES. By means of an introduction letter the researcher granted me,
the author of this paper, full permission to participate in the project as a research assistant. This was
explained to all respondents and copies of all three documents were always taken along and could be
shown in case I was asked to do so.
Next to respecting the formal research structures in Uganda, I also paid attention to the showing respect
for the local governance structures in the district. To ensure permission from the district I introduced
myself to the Chief Administrative Officer’s (CAO) office, the main bureaucratic office in the district,
before I started my fieldwork. In this way I aimed to show respect for and understanding of the local
hierarchy within the district. From the assistant CAO I got permission to carry out the research and was
allowed to ask for further assistance if needed. This was especially helpful in arranging the interviews
at sub-county level.
39
Ensuring confidentiality of the respondents, as was promised to them, is essential. This is guaranteed by
ensuring that no statements made can be traced back to one single person. In the coding and reference
structure of the interviews, people’s specific positions are not included. Also, in some cases the use of
direct quotations is refrained from, even if this means that some information is lost because of this. As
the scope of this case study is clearly defined and relatively small, it would otherwise be too easy to
trace certain statements back to specific individuals and confidentiality cannot be guaranteed anymore.
40
CHAPTER 4 - RESULTS
4.1 Analysis of the Level of Policy Integration
The first step in the analysis is to determine the level of policy integration in Ntungamo district. Each
of the four dimensions of policy integration is analysed with help of the relevant factors identified in
section 2.1.3. Using these factors, relevant findings are identified and discussed in relation to the
dimension which they influence most. Based on this a conclusion is drawn on what the level of policy
integration is for each of the four dimensions at district level in Ntungamo.
4.1.1 Frames
Frames is the first dimension for which the level of horizontal policy integration is assessed. The level
of integration is determined by discussing the problem perception of malnutrition as well as the
understanding of the multi-sectoral nature and the use of evidence. The existing structures in which the
nutrition policy is implemented are investigated to see if any of them shape the context in which nutrition
policy is implemented and are thereby of possible influence. In this way it can be determined whether
there is a shared understanding of the multi-sectoral nature and causes of the problem and whether the
existing institutional structure is enabling for implementation of nutrition policy.
Respondents indicate there is a wide variety of causes underlying the problem of malnutrition in
Ntungamo district. Feeding practices and a lack of knowledge about nutrition among the population in
Ntungamo is considered the most important cause. Families often consume only one type of meal and
knowledge about dietary diversity is insufficient (D/B-1,2,3,5,7,8,9; D/P-1; NGO-1,6,7; SC-1,4). Some
food that would make for a healthy addition to diets is considered to be for the poor or for children only,
which demonstrates that some cultural habits still have a negative effect on a healthy diet (D/B-1,8; O-
1). Another issue brought up in relation to food consumption is the unhygienic preparation and
packaging of food, especially school-going children their lunches (D/B-3,5; NGO-5). Community issues
that play a role are alcoholism, particularly among men (D/B-1,2,3,5,7; NGO-1; SC-1,2,3b), and
domestic violence (D/B-2,3,6,9; NGO-5; D/P-1; SC-1). Both have a negative influence on the
household’s ability to spend sufficient time preparing meals. Alcoholism, among other things, also
influences the amount of food that is sold by a family. Many families do not have the right balance
between the amount of food needed for their family and the amount they can sell on the market. Often
too much food that is produced by the household is sold and too little remains available for the family,
a dynamic that is worsened by alcoholism because the money raised by food sales is needed to buy
alcohol (D/B-1,2,3,4,5,7,8; NGO-1,6,7; SC-2). Based on respondents answers it can be concluded that
the causes of malnutrition in the district are understood to be multiple. A wide variety of causes is listed
and no contradictory statements are made, indicating that there is a shared understanding of malnutrition
being a complex problem.
41
The most important policy document on nutrition in Ntungamo, the District Nutrition Action Plan
(DNAP), also includes a list of causes. Comparing the causes mentioned by the respondents to those
listed in the DNAP two significant differences are found. In the DNAP issues related to health and health
care, and specifically the lack of attendance of antenatal care and the lack of information on the
importance of the first 1,000 days on the child’s development, are also listed as causes. Related to health
only two respondents refer to HIV/AIDS being an issue (D/B-3,9). Also, the DNAP adds a new category
of causes, namely those that have their origin in institutional issues. Things listed are the lack of specific
bylaws and ordinances for nutrition and the fact that there is no mainstreaming of nutrition issues in
work plans. Interestingly enough, respondents do not list any such causes. One can conclude from this
that although malnutrition is seen as a complex problem, the influence of institutional structures on
malnutrition is not fully understood by respondents. Apart from these two differences, causes listed by
respondents and in the DNAP are mostly similar and no contradicting statements were found.
This gives rise to the next question, which is whether respondents also have a good understanding of the
chosen policy type, namely a policy integration approach. It has already been seen that respondents do
not connect the institutional setting to the current situation of malnutrition. This is a first indication that
respondents might not fully understand the importance of policy types and institutional settings. The
dominating belief among respondents regarding how the nutrition problem should be solved is by the
fact that they believe that all sectors should work on it simultaneously (D/B-2,4,7; NGO-2,7; D/P-2; SC-
1,3a,4).
‘It is multi-sectoral because it takes in agriculture, which is production, it takes in education and it also takes in
health.’ (D/P-2)
However, essential for the understanding of policy integration is that work should be done across sectors
and that it should exceed the individual goals of the stakeholders in the governance system. The majority
of the respondents do not demonstrate this understanding. In their eyes programs and interventions,
either as part of Non-Governmental Organisation (NGO) programs or government programs, remain
separate entities. The focus is on avoiding duplication, rather than active collaboration between and
integration of different programs. In the DNAP the method of implementation of a policy integration
approach is also not further elaborated upon. Only a few respondents move beyond the idea that all
sectors need to be involved. They discuss things more in terms of how actions or problems in different
sectors interact and recognize relationships and trade-offs. They recognize that not just all sectors need
to be involved but that there also needs to be continuous interaction between the different domains (D/B-
3,6; NGO-5). As this is such a small number of the total respondents, it can be concluded that the
understanding remains at the level of the multi-sectoral nature of the issue. There is no full understanding
of how a policy integration approach should be implemented in the district, which is necessary to reach
a high level of policy integration.
42
Most of the statistics on malnutrition in the DNAP are from the Uganda Demographic and Health Survey
(UDHS) 2011 (at that time the most recent UDHS available) and apply to the wider South-West region.
Some other data used are from the SPRING baseline study, a Non-Governmental Organisation (NGO)
program that was active in Ntungamo until 2015. In the District Development Plan II (DDP II) section
2.3.4, but not in the DNAP, statistics on the number of people in Ntungamo, split up per sub-county,
that are stunted and anaemic can be found. Respondents from different stakeholder groups indicate that
they are aware that there is data that demonstrates that Ntungamo is doing poorly on nutrition:
‘At times, when we get some of these results from these people who are doing some research, they have published
in the newspapers that Ntungamo we have stunted children, the rate is high.’ (D/B-6)
However, they are unfamiliar with the exact details of the evidence and that they do not actively use it
in forming their opinion on issues around malnutrition. However, this does not seem to negatively
influence their understanding of the severity of the issue of malnutrition in Ntungamo district. Therefore,
it does not have a significant effect on the level of policy integration.
The existing structure is shaped by existing policy documents, the legal structure and the financial
structure. The most relevant document that guides the district in its development and shapes the
implementation of the DNAP is the District Development Plan II (DDP II). The DDP is the policy
document that sets out the direction in which the district should move between 2015/16 and 2019/20.
Interestingly enough, this document was not named by respondents and there are no indications that it
is considered relevant in the context of implementation of nutrition policy by anyone working on
nutrition in the district. The Uganda Nutrition Action Plan (UNAP), the central government’s nutrition
policy from which the DNAP follows, was referred to by two bureaucrats (D/B-2,5) and two Non-
Governmental Organisation (NGO) representatives (NGO-3,4). A few respondents also mentioned
national school feeding policies, whereas they are not listed in the section of the DNAP that lists a
number of policies to be guiding for in its design and implementation. This is most likely explained by
the fact that many of the largest programs on nutrition in Ntungamo are partially or fully implemented
at schools. Altogether, there are some documents that in theory should shape the context in which the
DNAP is written. However, they are not widely known among respondents and it is therefore
questionable whether they should be seen as relevant when considering the existing structure in which
nutrition policy is implemented.
The existing legal structure related to nutrition is very limited. Only two respondents (D/B-1,2) indicated
that there is a bylaw currently in place that is relevant in the context of malnutrition:
‘Currently, the ordinance that is there, they have not yet developed any ordinance on nutrition but there was an ordinance on alcoholism. Opening bars at two.’ (D/B-2)
As alcoholism is listed as one of the causes of malnutrition, it makes sense that the respondents believe
this bylaw to be relevant for the nutrition situation in Ntungamo. Other respondents say that there are
no bylaws relevant for nutrition, which is in line with the cause listed on institutional setting in the
43
DNAP. Legal documents were not collected during this research and can therefore not dispute or support
the claims made above, but all points towards a very limited existing legal structure. Both the legal
structure and existing policy documents do not seem to have much influence on policy integration.
Respondents are not familiar with them or do not consider them to relevant and there is no indication
that any of the content proposes a direction that moves away from a policy integration approach. The
existing documents and legal structure do thus not inhibit policy integration. Therefore, it can be
concluded that the existing documents and legal structure are not supportive but do not influence policy
integration negatively in any way either.
The existing financial structure in which the implementation of the DNAP is embedded is extensive. To
get more insight in this structure, Ntungamo’s annual work plans and quarterly performance reports of
the fiscal years 2015/16, 2016/17 and 2017/18 are used (for the exact list of documents see appendix 3).
The money flows that compose the district budget are: local revenue, discretionary (unconditional)
government transfers, conditional government transfers and other government transfers (for an overview
of the most important financial details see appendix 5). Donor funding is also mentioned by various
respondents as an integral part of the district’s budget:
‘The funding is from the central government, central government grants. We have local revenue and then also funding from partners.’ (D/B-1)
From the documents it can be seen that it is indeed listed as one of the money flows and is thus included
in the district budget. This is an interesting observation, as it indicates that the district sees the funding
from NGOs as a standard source of income, rather than as a fluctuating addition to their overall budget.
In the district financial structure, there is no separate budget for nutrition, which can be largely explained
by the way in which the finances in the district are structured. In Ntungamo’s planned budgets, the
central government transfers make up just under 90% of the total budget. In the realised budget, this
increases to over 95% (see appendix 5). The majority of these transfers exists of conditional grants,
which therefore compose the largest share of the district budget. The conditional grants are sectoral,
meaning that they are channelled via one department and cannot cut across or be shared among multiple
departments. By district bureaucrats they are characterised as inflexible. The sectoral nature of the
conditional grants are not in line with the multi-sectoral nature of nutrition issues and there is currently
no such grant in place for nutrition, forming a barrier for policy integration.
The only part of the budget over which districts have full freedom in deciding what they want to spend
it on is the local revenue. However, over the last three years, realised local revenue made up about 2%
of the total realised budget. The local revenue that Ntungamo district expects to raise is consistently
overestimated. Only between 50-75% of what was planned for has been realised during the last three
fiscal years (see appendix 5). This is also noted by some of the district bureaucrats (D/B-1,8,9), who
44
point out that ‘local revenue is limited and also reducing’ (D/B-8). As the district can themselves decide
over this budget they could spend it on nutrition, but that is currently not the case. If this would be done,
the budget would still be small as local revenue is low. Overall, the financial structure strongly inhibits
policy integration. Its sectoral structure and a total lack of autonomy in decision making on what the
budget should be spent on does not align with the multi-sectoral nature of malnutrition. The existing
structure has made it impossible to create budget for an integrated approach.
To reach a high level of policy integration at district level there should be a shared understanding of the
multi-sectoral nature and causes of the problem, as well as an enabling institutional context. Clear is that
the multi-sectoral nature is understood, because different causes originating in different sectors are
listed. Although the use of evidence is minimal, it does not seem to limit understanding of the complexity
and severity of malnutrition. However, a policy integration approach is not fully understood.
Respondents believe that different departments need to work on the issue at the same time, but there is
no indication that they work across departments. Because there is no full understanding of policy
integration, namely that it is not recognized that work needs to be done across departments and in
collaboration with other stakeholders, means that full horizontal policy integration will be much more
difficult to achieve. Existing structures are limited and there is no indication that they are of great
influence. Therefore they are not strong determinants in the (policy) context in which the DNAP is
implemented. The only exception to this is the financial structure. The budgets are organized per
department, meaning they follow sectoral lines rather than the multi-sectoral nature of malnutrition. This
makes horizontal integration difficult, because the financial structure does not allow work to be done
accordingly. Overall there is a medium level of policy integration, as there are still too many boundaries
to work across departments and there is not a strong enough understanding of or push for integration.
4.1.2 Subsystems
To assess the level of policy integration for subsystems the actors and institutions and the way in which
they have organised themselves into different bodies is looked at. The level of formality of the bodies
as well as the density of interactions between them is assessed to understand the activity of each
individual body and the connections between them. Commitment in the governance system is analysed
to create a better understanding of what might inhibit or support actors and organisations to be active on
nutrition. Altogether, this makes it possible to assess the level of horizontal policy integration for
subsystems.
The actors most active on nutrition in Ntungamo are part of the district bureaucracy and various different
NGOs. Within the district bureaucracy, the production, education and health departments are most
active. Other departments, such as community development, planning and finances, are also involved,
but to a lesser extent. The involvement of a relatively wide range of district departments fits with the
45
multi-sectoral nature of nutrition and is a good starting point for a policy integration approach. There
are ten nutrition programs in the district. The Uganda Multi-Sectoral Food Security and Nutrition
Program (UMFSNP) is a government program and coordinated by the production department. The nine
other programs are run by Non-Governmental Organisations (NGOs). Six of these NGOs have also
attended at least one meeting of the District Nutrition Coordination Committee (DNCC) meeting, which
will be discussed further later in this section. Next to that, district politicians and other stakeholders are
also involved in nutrition in the district, albeit they are much less visible and active. At district level two
bodies were identified to be relevant in the context of implementation of nutrition policy, which are the
DNCC and the district milk taskforce. The DNCC was found to be most important for the
implementation of nutrition policy in Ntungamo district and is therefore discussed in most detail.
The DNCC is the main coordination mechanism for nutrition policy in Ntungamo district. Its
membership is composed primarily of district bureaucrats and NGO representatives of organisations
working on nutrition in Ntungamo. Next to that, sub-county government officials and others involved
in nutrition sometimes also attend DNCC meetings. Based on the member’s attendance (see appendix
6) it can be concluded that there is much variation in the composition of the DNCC. The total number
of people present at meetings has varied from 7 to 21 people and in total 27 different functions or
organisations have been present at one or more meetings. This shows that the group of DNCC members
is likely not to have been well-defined when the DNCC was put in place. The most active members,
those that have attended more than half of the meetings, are all district bureaucrats. This coincides with
the respondents’ answers on whom they believe to be the most active members, which are the district
agricultural officer (D/B-1,2,3,7,8,9; NGO-1,2,4,5,6,7), the health department (D/B-1,2,7,8; NGO-
2,4,5) and the education department (D/B-2,8,9; NGO-2,4,7). It is thus clear that within the DNCC, the
district bureaucracy takes the lead. This makes sense taking into account that the DNCC is a government
structure. Activity from the NGO representatives, both in terms of whether or not they attend DNCC
meetings and how frequently they attend, varies. As stated above, six of the nine active NGOs in the
district have attended a DNCC meeting. This indicates that some NGOs are more connected to the
district’s governance structures than others and therefore interact with the district bureaucracy more
frequently. The attendance lists show that there are no politicians in the DNCC, but various respondents
did list people from the political wing (e.g. the district chairperson) as DNCC members (NGO-6, D/P-
1,2,3, O-1). Interestingly enough, all those misunderstanding this were from the political wing
themselves or actors from organisations. None of the district bureaucrats stated politicians were part of
the DNCC. This shows that those that most often attend DNCC meetings are also best familiar with its
membership.
The vision and mission of the DNCC are formulated without much discussion during one of their first
meetings in June 2015. However, the outcome is a rather vague description that does not appear in any
46
other document and is not familiar among the respondents. When respondents are asked about the goals
or the mission and vision of the DNCC, they give answers that describe the DNCC more in terms of
tasks. Only two respondents make a link between the work of the DNCC and wider policy goals, which
the respondents are also not well-acquainted with. Members find it much easier to list tasks they believe
the DNCC to be responsible for and list a variety of them. It should coordinate the nutrition activities
implemented by partners, ensure there is no repetition of interventions and work to ensure sustainable
effects of these interventions (D/B-1,2,3; NGO-2,3,4; SC-1). The DNCC should also do monitoring and
evaluation of nutrition activities (D/B-1,3,8,9; NGO-4,5), work on nutrition action plans (D/B-4,5; D/P-
2) and advocate for nutrition (D/B-1, NGO-4). Lastly, they should do trainings and sensitizations and
monitor the functionality of and provide guidance for the Sub-county Nutrition Coordination
Committees (D/B-2,3,5,8; NGO-4,5,6; SC-1). The tasks listed by the respondents is mostly similar with
the tasks of the DNCC stated in the minutes of June 2015:
‘Roles and responsibilities of DNCC which were summarised into providing technical guidance about nutrition
issues. Coordination of nutrition activities, monitoring and evaluation of nutrition activities, planning and budgeting
and advocacy and awareness creation about nutrition.’ (DNCC minutes June 2015)
Technical guidance is not as explicitly mentioned by the respondents, but things such as monitoring and
evaluation do fall under this category. The only clear difference is that budgeting is not seen as a DNCC
task by the respondents, whereas it is included in its original mandate.
Based on the respondents answers and the description of roles and responsibilities of the DNCC it can
be concluded that there is a largely shared idea of what the DNCC should do. The only major
misunderstanding about the DNCC’s tasks is that some respondents see it as an implementing body.
This confusion arises from the fact that the biggest program on nutrition in the district, the UMFSNP, is
a government program headed by the district production officer, who is also one of the most active
members of the DNCC. Some respondents therefore connect the DNCC’s tasks to the activities of the
UMFSNP and when asked about the DNCC they refer to the activities of this program rather than the
DNCC as a whole. However, the DNCC is not responsible for the implementation of programs or certain
activities, for example monitoring in health facilities (NGO-5; D/P-3; SC-3b). However, comparing the
few misunderstandings to the total number of answers given it can be concluded that the DNCC’s tasks
are well understood by the respondents. Also, they are largely similar to those that were formulated
when the DNCC was installed.
One issue that prevents the DNCC to be fully functional and carry out all its tasks properly is the lack
of resources (D/B-3,8,9; NGO-4; O-1; D/P-2). When the DNCC was set up, it was sensitized and funded
by the Food and Nutrition Technical Assistance (FANTA) program. Now it receives some funding from
the Uganda Multi-Sectoral Food Security and Nutrition Program (UMFSNP). Various other NGO
programs, such as RHITES, continue to play a role in supporting and training the DNCC (D/B-8; NGO-
47
4,6). Respondents claim that from the beginning, the functionality of the DNCC has depended largely
on the funds available from partners (NGO-2,3,5; D/B-8). One of the reasons for this is that funding
nutrition activities is not a priority in the district (NGO-1,3). The fact that funding is received from
NGOs and there is no district nutrition budget supports this claim. Apart from the point of funding,
respondents are not coherent in their answers about what barriers the DNCC experiences and which
improvements should be made. There is thus a clear understanding of what should be done, but not
necessarily of how this can be implemented in practice. This is most likely related to the finding that
respondents are also not fully familiar with how a policy integration approach works. They are not
familiar with the policy type and therefore logically, also do not know how the functionality of the body
that should work on the implementation of this policy type can be improved.
Clear is that the DNCC is in place and functions to some extent, thereby helping to increase the level of
horizontal policy integration. It brings different actors working on nutrition in the district together and
allows them to communicate with each other. Thereby it helps to create a situation in which actors can
explore possibilities to work together across departments and organisations and share information.
However, some improvements can still be made. Respondents still understand communication primarily
in terms of information sharing about each other’s activities (D/B-1,9; O-1; NGO-5,7,8).
Communication more focused on integration, such as coordination of NGO activities or combined
planning of interventions, is barely mentioned. Information sharing only happens during meetings,
which limits the density of interactions between the actors that are active in the DNCC. This, combined
with the irregular attendance of DNCC meetings, means that communication is sub-optimal and does
not lead to reaching the full potential of horizontal policy integration one would hope the DNCC to
contribute to.
The other communication and coordination mechanism active in the district is the district milk taskforce,
which is part of a program run by the NGOs ARISE and SNV Dutch Development Organisation. It was
set up more or less simultaneously with the DNCC and has many of the same members as the DNCC.
The two main differences in member composition are that the milk task force also includes politicians
and the DNCC includes a wider range of NGO representatives. The milk task force's scope is more
limited than that of the DNCC, as it focuses on one program and not on all nutrition activities in the
district (NGO-2,3). Apart from that, the approaches are very similar and according to some, such a
parallel structure should therefore not exist:
‘If SNV is coming to the district to promote school feeding it shouldn’t again create a separate body to own up the
school feeding, to spear lead that. [..] So instead of that different body they should be owning, proposing why don’t
we use this structure already existing because the same members we have for the task force that is spear leading
school feeding are the same members as the DNCC.’ (NGO-2)
Looking at the district structures as explained in chapter 2, one could argue that there is another body
one would expect to be relevant for implementation of nutrition policy, but is missing in the respondents
48
answers. This is the District Technical Planning Committee, which is not mentioned by anyone. The
only exception to D/B-1 who mentions that, as explained, this is the body to which the DNCC delivers
its input for policies and related things. One would therefore at least expect it to be mentioned as a
relevant actor in the context of nutrition policy. The fact that it is not mentioned makes it questionable
whether the Technical Planning committee plays any active role in the implementation of nutrition
policy and can be considered a relevant body in the governance system.
For an ideal situation of horizontal integration one would want multiple coordination and
communication bodies to exist and function, and enjoy some degree of authority. All of them should
have developed ideas about their individual roles and responsibilities and interact and collaborate
actively. However, in Ntungamo the number of formal and active coordinating bodies is limited to the
DNCC. Compared to the DNCC all other bodies or structures identified are more informal, less function
or a combination of the two. Bodies of NGO programs, such as the district milk task force, are not well
known enough among a large variety of actors. Also, the specific case of the district milk task force is
too focused on one program to be a truly coordinating body and it does not include a large enough
variety of actors. For other bodies of which it is expected that they are active, such as the Technical
Planning Committee, no such evidence is found. This creates a situation in which there is a very limited
range of active bodies in the governance system, thereby making the DNCC is the dominant body. This
has a negative influence on policy integration because there are fewer opportunities for interactions,
resulting in low density of interactions, and the possibilities to work across sectors and organisations are
limited. Also, one wants the coordination and communication bodies on nutrition to have a certain
degree of authority, so that they have the mandate to take decisions that benefit horizontal policy
integration, which the DNCC does not seem to have. The DNCC is functional, but its dependence on
NGO funding and the misunderstandings around the fact that it is an implementing rather than
coordinating body make it lose some of its potential authority. Overall the DNCC contributes to policy
integration, as its existence is a first step in creating an active governance system with a high density of
interactions. However, improvements need to be made to realize its full potential. Its fluid membership
and irregular attendance needs to be improved to be able to take decisions that affect integration of
nutrition policy across the district and to stimulate cooperation across departments and organisations.
One of the reasons that explains some of the functionality issues of the DNCC is the level of commitment
in Ntungamo district. In Ntungamo there is significant political attention for nutrition. The district
chairman is widely considered to be a ‘champion of nutrition’. Many recognize him as a leading figure
when it comes to advocacy for nutrition (D/B-1,2,7,8; NGO-1; O-1; D/P-1, SC-3a,3b,4):
‘Every talk show he attends on radio at least he [district chairperson] chips in issues of nutrition. He is one of the
champions of nutrition in the district.’ (D/B-8)
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As the political head of the district, his support is essential in raising awareness for the issue. However,
respondents also recognize the need for other politicians to be engaged, as they too are able to reach
large numbers of people, for example at public gatherings. The opinions on whether they engage actively
differ. Some say that they are actively advocating for nutrition (D/B-2,6,7; NGO-1; O-1; SC-2,3b,4),
but others argue that their attitude towards nutrition is problematic or that their level of knowledge is
low (D/B-1,5,8; D/P-1,2; SC-1,3a). Many respondents also agree that although politicians are supportive
of the message of nutrition they could be doing more (D/B-3; NGO-2,5,6; D/P-1,2,3).
In documentation collected during this research little evidence is found that showed that there has been
much attention for nutrition in sub-committees of the district council or the district council itself. In
February 2016 the District Nutrition Action Plan is approved by the council without much discussion.
Interestingly enough, it is stated in the council minutes that the DNAP is not necessarily seen as a
working document, but as a way to attract funding:
‘The District council approves the Nutrition Action Plan 2015-2020 to make it a working document that can attract
development partners and donors focused at addressing the challenges.’ (Ntungamo District Council Minutes
February 2016)
This brings us to political commitment, which is defined as that it should be ensured that necessary
resources are allocated. The way in which the DNAP is described by the council indicates that the district
either does not have or does not prioritize to budget a sufficient amount for nutrition. Also the local
revenue is not spent on nutrition activities and respondents therefore believe that the council could do
more to ensure nutrition gets allocated the necessary resources (D/B-1,8,9):
‘The fact that they are conditional in a way hinders the implementation of nutrition activities. But if there was political
will at the district level at least part of local revenue could be used to address issues of nutrition.’ (D/B-8)
Overall, there is no indication that political attention has led to a political commitment in Ntungamo
district. This means that yet another body that one would hope and expect to be active and relevant in
the implementation of nutrition policy is not operational in the context of nutrition. This negative affects
the range of active bodies in the governance system as well as possibilities of interaction on the topic.
Lastly, there is system-wide commitment. The definition of this is that not only the politicians, but also
managers and implementers are committed to and work on the implementation of nutrition policy. As
previously stated, the DNCC is in place and meetings are attended by a variety of stakeholders, including
active district bureaucracy. However, some respondents raise questions around whether the recognition
of nutrition as a multi-sectoral issue has not led to a loss of leadership in the governance system. As
there are many departments involved, they feel it is unclear whether if so which department should be
in the lead:
50
‘But again when nutrition was made a multi-sectoral issue, like it used to be, like I said the home used to be in health
department, but now when it became multisectoral sometimes it, oke, it has nowhere to lie because everyone says it
belongs here, it belongs here.’ (D/B-7)
Two solutions to this problem are suggested, namely that a person or department takes the lead or that
nutrition gets its own office (D/B-1; NGO-1,2). If either one of these solutions are implemented, this
could cause significant changes to the current situation and level of system-wide commitment. This, in
combination with the lack of financial resources, limits actors in the governance system to do all the
necessary work on implementation of nutrition policy.
Overall, it is clear that there is political attention for nutrition in Ntungamo. The leadership role of the
district chairman is essential for this. Using his position, he advocates strongly for wide involvement
across the district on nutrition and thereby positively influences policy integration. Recognition of the
importance of the topic is a first step to generate attention for it and set in motion further action.
However, attention has not led to political commitment. There are no sufficient resources for nutrition
and not all politicians seem equally interested in the issue. Although there is no full political support,
actors try to create system-wide commitment. Nutrition is recognized to be important and stakeholders
are actively involved on the topic by participating in the DNCC. However, with insufficient resources
are ensured through political commitment and questions around leadership within the district
bureaucracy make further action difficult. This means that although the first step of attention for nutrition
is taken, positively influencing policy integration, the full potential is not realized. Without commitment
further necessary conditions for the governance system to function in a fully integrated way, such as
resources, are not put in place and a higher level of policy integration is not achieved. This, in
combination with the limited number of bodies active in the district’s governance system and the
relatively low density of interactions, results in a low to medium level of policy integration for the
dimension subsystems.
4.1.3 Policy goals
To assess the level of horizontal integration for policy goals the range of documents in which nutrition
is included and the coherence between the goals in these documents is considered. As literature did not
provide much more insights into what could possibly be relevant factors analysis is limited to these two
points and agreement on expected results.
In Ntungamo the main policy document on nutrition is the District Nutrition Action Plan (DNAP). Next
to that nutrition is discussed in the District Development Plan II (DDP II). Both documents apply to the
time period 2015/16 to 2019/20. There are no other indications that departments have included nutrition
in their policy documents and in the financial work plan none of the departments have included activities
that aim to address nutrition issues. This means that nutrition is most likely only addressed in a very
limited number of policy documents.
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The DNAP is the only document that includes a policy goal on nutrition. The DDP has not stated a
specific goal, but did formulate various objectives. Comparing the objectives for nutrition formulated in
the DNAP and the DDP, it can be seen that these are not aligned. The DNAP states three main objectives,
whereas the DDP states five. Goal 1 and 2 in the DNAP are found in the DDP in the exact same wording.
Goal 3 of the DNAP is partially included in the DDP. The two additional objectives found in the DDP
are not included in the DNAP:
Table 4
Comparison of policy objectives in the DNAP and the DDP
Policy objectives DNAP Policy objectives DDP
To strengthen and harmonise multi-sectoral
coordination framework for nutrition (p. 20) Strengthen and harmonize multi-sectoral
coordination framework for nutrition (p. 114)
To improve access and utilization of services related to
maternal infant and young child nutrition (p. 22) Improve access to and utilization of services related
to maternal, infant and young child nutrition (p. 105)
To enhance the knowledge and skills of households on
production and consumption of diversified foods (p. 25) Enhance consumption of diverse diets (p. 113)
Improve nutrition in schools (p. 114)
Address gender and social cultural issues that affect
nutrition (p. 115)
Diving further into the coherence of the documents, it can be concluded that coherence is no better in
other sections. The DNAP, the DDP and the Multi-Sectoral Nutrition Action Plan (MSNAP) mid-term
review1 all include a strategy framework for implementation of nutrition activities in Ntungamo. The
coherence both between and within these strategy frameworks is low. One such example is the objective
‘To enhance the knowledge and skills of households on production and consumption of diversified
foods’ (p. 25) in the DNAP. For this objective, several strategies are outlined, one being ‘promote
consumption of diverse nutritious foods’ (p. 25). This strategy includes multiple interventions for which
three departments; health, community development and production, are responsible. Two examples of
interventions are:
• Conduct radio talk shows about food consumption and spot messages about good nutrition practices
• Promotion of labour saving technologies for women (p. 25)
The intervention to conduct radio talk shows is mentioned two more times under different strategies,
each time with slightly different wording. It is thus repetitive and links between the different strategies
and possibly overarching interventions are not made. For the second intervention there is no clear link
1 1 Although the documents have slightly different names, the MSNAP mid-term review is the mid-term review of the
DNAP. Both the DNAP and the MSNAP thus refer to the same policy.
52
to nutrition and no outputs are defined. This shows that the objective, strategies and interventions are
not linked well and do not logically translate larger objectives into practical interventions.
Comparing this objective to similar objectives in the DDP and the MSNAP, it can be seen that in neither
of them the wording or structure of the strategy framework is the same. In the DDP the most similar
objective to the objective from the DNAP previously mentioned is ‘enhance consumption of diverse
diets’ and the most similar strategy is ‘strengthen production of diversity, nutritious foods and micro-
nutrient enhanced rich foods at household’ (p. 113). Only two sectors, health and production, are
responsible for this strategy. The interventions are not the same as in the DNAP and only outcomes, but
no outputs are defined. In the MSNAP the most similar objective is ‘To enhance the knowledge and
skills of household on production and consumption of diversified foods’ (p. 23). Again, the strategies
defined are not similar to either those in the DNAP or the DDP and in this strategy framework a
responsible department is appointed per intervention, rather than per strategy. Of course, there are also
similarities in the objectives, strategies and interventions of the three different frameworks. However,
the wording and structure of each of them is different, which causes confusion over what exactly the
policy objectives and interventions are. This leads to an overall low level of coherence. It has a strong
negative effect on horizontal policy integration, because it poses a high risk for those working on
nutrition in the district in two ways. Firstly, different frameworks might be used, which means that
objectives, strategies and interventions are not aligned between different stakeholders. Secondly, even
if the same framework is used by everyone, confusion can still arise over repetitive and vaguely
formulated interventions in relation to nutrition. This makes effective collaboration between
stakeholders more difficult and time-consuming, as much more effort needs to be spend to align
everything and come to a truly integrated approach.
Whether the goals in the district’s documents are leading for stakeholders is an interesting question to
consider. Taking into account that NGOs are stakeholders at district level, they should make use of
district documents to reach a high level of policy integration. The NGOs see the district and their policies
as giving direction or guidance to their programs (NGO-1,4,5,6,7). At the same time, it is pointed out
that an NGO program always has the autonomy to determine its own objectives (NGO-1,3; D/B-1):
‘That is bound to happen because for as long as something is a project they come with their own objectives and they
do whatever they want to do.’ (NGO-3)
There are currently no signs that objectives of NGO programs and district policies are colliding.
However, the NGOs are in no way bound to the district’s policy goals. This makes policy integration at
district level vulnerable, especially in a situation where Ntungamo is strongly dependent on donor
money to implement most of its nutrition activities.
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This also relates to the point of agreement on expected results. In an ideal situation for policy integration,
all stakeholders should jointly work towards the goals. To determine whether this is the case
stakeholders need to be aware of the existence and content of the policy documents. However,
respondents struggle to even name the DNAP. Only five bureaucrats (D/B-1,2,5,7,8) and one politician
(D/P-2) were able to mention it by name, which is a low number considering that this is the leading
policy document on nutrition in the district. Except for one district bureaucrat (D/B-7) no one was able
to recall any of the policy goals or objectives in the DNAP. Therefore, no conclusions can be drawn on
whether there is agreement on exactly what goals in Ntungamo stakeholders work towards to improve
nutrition. The only thing that is clear, as also explained under frames, is that they understand the severity
of the problem and recognize the need for action. This is a first, but small step, towards policy integration
as it remains uncertain what exactly needs to be done.
Overall it can be concluded that the coherence both within and between existing policy documents is
low. There is also no overarching strategy that works across the different departments, because the focus
of the documents remains sectoral. Getting to a level of high policy integration, where all actors
including the NGOs work towards the implementation of a coherent set of policy goals does therefore
not seem to be in reach. The level of policy integration of policy goals is therefore low.
4.1.4 Policy instruments
The level of policy integration for instruments is assessed by looking at the types of instruments used to
implement nutrition policy, the mix these instruments together form and the available capacity to
implement them. This together forms a picture of the level of integration of the dimension policy
instruments.
The strategy frameworks in the District Nutrition Action Plan (DNAP), the District Development Plan
(DDP) and the Multi-Sectoral Nutrition Action Plan (MSNAP) mid-term review all contain many
interventions, or in other words, suggestions for policy instruments. These are linked to strategies and
depending on the framework, at least one or at most three departments are responsible for the suggested
instrument. The majority of the instruments in the frameworks are substantive instruments, meaning that
they aim to directly influence service delivery. To achieve this, the aim of the instruments is to establish
facilities, conduct demonstrations, give trainings and provide advice and services, predominantly in
relation to production, education and health and to a lesser extent aimed at improving community
development and water and sanitation. The formulation of the instruments is in most cases relatively
specific, meaning it is clear where and how action should be undertaken. However, as also explained
under policy goals, the structure of the strategy frameworks is focused on departments. Even when two
or three departments share responsibility, from the way the instrument is formulated it is often still very
clear where the main responsibility lies. The substantive instruments therefore do not encourage working
across boundaries, limiting opportunities for policy integration.
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A much smaller range of instruments can be classified as procedural elements. These instruments strive
to achieve the objective ‘to strengthen and harmonise multisectoral coordination framework for nutrition
activities’, which is included in all three documents (the DNAP, the DDP and the MSNAP). Strategies
for this objective are to improve the quality of nutrition coordination structures and advocate for
nutrition. The interventions for these strategies range from orientation of the DNCC members about
their roles and responsibilities, supporting schools to develop work plans and budgets, conduct
assessment for nutrition issues and mainstream nutrition in all sector plans and budgets. Some of the
procedural instruments are formulated in rather concrete terms, whereas others are very broad and do
not make clear what should be done exactly. Also, many of them do not directly relate to the above
stated objective. The responsibility for these interventions lies with the administration and planning
departments, but also with health, production and the DNCC itself. Especially the last three mentioned
departments are a rather illogical choice to give responsibility to for these types of interventions. For
health and production it is difficult to work across structures, as there is no enabling structure that allows
for this. The DNCC does not have the means to implement policy, as it is a coordinating but not an
implementing body. Therefore, making them responsible for part of the implementation of procedural
instruments makes it much more likely that this will fail. Overall, this means that an attempt has been
made to formulate some procedural instruments, but that formulation and specificity needs to be
improved and in various cases, the choice of department that is responsible for the implementation is
not logical. To reach a high level of policy integration, all of these points will first need to be improved
significantly.
There are two problems with the capacity that is needed for policy instrument implementation. Firstly,
implementation of policy instruments cannot be financed. As stated under frames, there is no nutrition
budget in Ntungamo District. Theoretically, substantive instruments could be financed by integration
them with other activities, so that they can be financed from the sectoral structure. However, whether
this integration of nutrition activities into different department’s other activities happens is questionable.
Respondents indicate that nutrition is not given priority and that integration of nutrition into other
activities rarely works out in practice (D/B-2,5,7,8):
‘They have been saying you agriculture, budget for nutrition, health budget. But you find those what, those sectors
are not giving nutrition a priority.’ (D/B-2)
In practice it therefore does not seem realistic to assume that any of the substantive instruments are
financed with resources from the sectoral structure. Finding financial resources for the procedural
instruments is even more difficult, as they often need to be implemented across sectors. There is no
district budget that allows for this. The only other budget available seems to be funding from partners.
Various respondents state it is almost solely because of donor money that the DNCC structure is
supported to some extent. Respondents raise questions about the sustainability of this donor money, as
55
donor priorities change over time, programs end and donors can decide to leave the region
(D/B1,2,3,7,8,9; NGO-3; SC-2):
‘The government, you see, this NGO funding is not sustainable. Until when the government streamlines nutrition in their program and budgeting process, that is when the DNCCs can work.’ (NGO-3)
Next to that, most donor money is probably not channelled via the district but goes directly from the
organisation to the implementation of activities. The donor money that is channelled via the district is
only a small amount and in no way enough to support the implementation of multiple substantive or
procedural policy elements. Overall, the financial capacity to implement nutrition policy is very limited
and does not allow for adequate policy integration. The dependence on NGO funding is problematic for
long-term sustainability and the loss of this funding might in the future undo any level of policy
integration reached.
Secondly, there are issues with human resources. Respondents do not necessarily feel there is a shortage
of people and also indicate the level of knowledge of those working on nutrition to be sufficiently high
(D/B-1,7; NGO-2,3,7; D/P-3). However, they do indicate that many working on nutrition have a lack of
interest in the topic or do not prioritize it enough. Especially politicians are not considered to be
interested, as explained under subsystems. However, also others involved, such as the district
bureaucracy, do not prioritize nutrition when decisions need to be made (D/B-1,7,8; D/P-1,2; NGO-2,4).
This means that across the governance system, those that work on the topic or can increase attention for
it do not bring it under the attention as much as they could. This has a negative impact for generating
attention for nutrition in general, and more specifically for the implementation of policy instruments. A
higher level of interest could help to create a better understanding and higher level of policy integration,
which is now not achieved.
Overall it can be concluded that the level of policy integration for policy instruments is low. Substantive
instruments are formulated along sectoral lines and dominate the instrument mixes compared to
procedural instruments. Also, procedural instruments are formulated in general terms and choice for
appointment of responsible department is in various cases illogical. The capacities needed to support
implementation of the instrument mixes are insufficient and do not in any way stimulate an integrated
approach. The consistency across the instrument mix as a whole can still be improved, which also relates
to the points made under policy goals. The instrument mix is too fragmented to achieve policy
integration. Consistency is not an explicit aim and neither is working on implementation across sectors.
Therefore, instruments do not contribute much to reaching a high level of policy integration.
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4.2 The Effects of Decentralisation on Policy Integration
The second step in the analysis is to determine the effects of decentralisation on policy integration by
looking at the dynamics of vertical coordination between government levels, as defined in section 2.1.2.
Using the findings gathered by looking at vertical coordination, the expectations formulated in section
2.2.2 are evaluated to determine the effects of decentralisation on policy integration. Additional findings
on which no expectation was formulated are also included.
4.2.1 Communication and coordination
The expectation formulated was as follows: it is expected that vertical communication between
decentralised government levels can be a barrier in creating a clear mandate on coordination
responsibilities for each horizontal government level.
The main focus of this expectation was whether the composition, structure and tasks of the District
Nutrition Coordination Committee (DNCC) were communicated well from central to district level. As
concluded under subsystems, the DNCC is in place and has a wide variety of members from both the
district bureaucracy and Non-Governmental Organisations (NGOs), as is prescribed in the guidelines
explained in section 2.2.2.1. The tasks listed by respondents are also largely similar as how they are
described in the Uganda Nutrition Action Plan, the exception being that the DNCC does not seem to
have much contact with the Technical Planning Committee. Based on the findings under subsystems it
can be concluded that communication from the central level to the district level about the tasks of the
DNCC, as outlined in the UNAP, has been successful. The autonomy of the district level did not stand
in the way of communication, indicating good vertical coordination. However, when asking people
about how the DNCC was set up, an interesting influence came to light, which is that of the NGOs. For
funding and (part of) its training the DNCC has since its inception been dependent on NGOs. Therefore,
one can argue that NGOs rather than the central level have been responsible for successful
communication about the structure and responsibilities of the DNCC. This means there is a third relevant
actor this vertical structure, that supports communication between the central and district level. This
makes it questionable whether communication between the two levels is as successful as it seems at first
sight or whether, also as a result of decentralisation, a third party in the form of NGOs is needed to make
this process go smoothly.
Another aspect relevant for this expectation which was not discussed in the expectation is the
communication between the district and sub-county. Another one of the responsibilities of the DNCC is
the orientation of the Sub-County Nutrition Coordination Committees (SNCCs). However, based on the
respondents answers it is questionable whether this was done. The SNCC orientation report states that
the orientations should have taken place between February 2017 and June 2017, but it is difficult to
verify this. According to the Multi-Sectoral Nutrition Action Plan (MSNAP) mid-term review 12
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SNCCs have been oriented (p. 12), but it is not clear which sub-counties this concerns or when it took
place. The DNCC minutes of February 2017 say the following:
‘He [ACAO] informed members that going to the sub counties to orient the SNCCs about their roles and responsibilities was the activity that was going to follow. He also informed the members that the funds to facilitate the process were already processed and the only arrangements remaining was to make schedules of how to move to different sub counties.’ (DNCC Minutes February 2017)
However, in later meetings (November 2017) it is stated that intensification of sensitizations and a
follow up of the functionality of nutrition coordination structures at lower local government level needs
to happen. Also in the document ‘Ntungamo District Start Up Action Plan for Nutrition Coordination
Committees 2017/18’ various such activities are listed. Altogether, this indicates that even when
orientation did happen, it is unlikely that it was fully completed and follow-up is necessary.
In addition to this, respondents give little reason to believe that the SNCCs are in place and functioning.
The majority answer that they are not functioning at all or not fully functioning, although some say that
they have been installed (D/B1,6,7; NGO-5,6,7,8; D/P-3). A minority argues that some of the SNCCs
are functional (D/B-3,8; NGO-7). One factor that respondents believe to determine whether there is any
functionality is the presence of partner organisations in the sub-county (D/B-7,8; NGO-6,7).
‘I don’t think they have done anything. Because they made a program, they were supposed to come. We waited for
them but up to now. In other sub-counties, not all, they went there, but maybe it’s because we have said that this
nutrition they don’t have a budget. Maybe they failed to come because of that. But they have already told us that they
were supposed to come at our sub-county but they never came.’ (SC-1)
None of the sub-county representatives claim their own SNCCs to be fully functional, if they say that
they are functional at all. In Ihunga and Bwongyera there is no SNCC in place and members have not
been appointed. In Bwongyera this is partially attributed to the fact that the sub-county has been in
transition and therefore did not have the means to set up any new structure. In Kayonza a
structure, which includes the sub-county chief, community development officer, agricultural officer,
health assistant, the secretary for health and the secretary for women’s and children’s affairs, is in place.
Tasks that they believe are part of the mandate are to discuss and make nutrition plans, integrate nutrition
activities and conduct monitoring and evaluation. According to their representatives, there have been no
meetings so far because the nutrition project (the UMFSNP) largely by-passed the sub-county. The
committee is thus not active. Whether there is a SNCC structure in place in Nyakyera remains unclear.
One of the two respondents argues that it is not in place, whereas the other says there is something in
place. The members of that committee listed are not the ones that would normally be in the SNCC. It is
therefore more likely that is a structure of a project. The explanation most commonly given about why
the SNCCs are not functional is because funding is not sufficient, even with money from partners (D/B-
1,3,5,6,8; NGO-3,6,7,8; D/P-1,2; SC-2). Also the sensitization and orientation that was promised to
them but is not (fully) delivered upon is an issue. Altogether, this confirms that the DNCC has not been
fulfilled its responsibilities towards the sub-county government level.
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In a decentralised system levels have far-reaching autonomy, but this does not mean that they should be
completely disjointed from each other. However, decentralisation is likely to play a significant role in
the fact that the DNCC has not carried out its responsibilities to orient the SNCCs. Because of the high
degree of autonomy each level the district is solely responsible for performance at its own level. There
is little added value for the district to spend its limited resources on this orientation. It is therefore logical
that the district prioritizes the functionality of its own DNCC. Setting up a coordination structure at
lower level requires significant capacity of different kinds, which the district does not have. However,
neglecting its responsibilities with regards to vertical coordination can also have an indirect negative
influence on horizontal integration. The governance system as a whole is not as large nor as strong as it
could be. The SNCCs cannot participate as active bodies because they are not functional, which reduces
the total number of active bodies. It also limits possibilities of interaction, thereby decreasing the number
of interactions in the governance system. This has a negative effect on the dimension frames. Also,
without active SNCCs it is less likely that there is capacity or support to implement nutrition policy on
the ground increasing problems for the dimension policy instruments. Therefore, the lack of vertical
coordination between the district and the sub-county negatively influences several aspects of horizontal
policy integration. Interestingly enough this is in contrast with the coordination between the central level
and districts, which is executed well and has helped to establish a DNCC that is functional, thereby
making a positive contribution to policy integration.
4.2.2 Human resources
The expectation formulated was as follows: It is expected that decentralisation has a negative influence
on the availability of human resources to ensure successful horizontal policy integration of nutrition
policy at lower government level.
There is a relatively large number of people working on nutrition in the district, which can be deduced
from the number of active members in the District Nutrition Coordination Committee (DNCC).
However, there is only one person in the whole of the district that has nutrition as their main priority,
which is the district nutritionist. This person does not only work on nutrition in the district, but has to
divide its time between the district and the hospital. This means that there is no one working at the
district full time with nutrition as its main priority. The presence of the nutritionist does mean there is
specialised knowledge which can be used for consultation. Also, most people at district level are
relatively satisfied with both their own and other people’s knowledge on nutrition. This can be explained
by the fact that they have received training by partner organisations, for example through the DNCC.
However, under the dimensions policy goals and frames it was seen that there is only a basic level of
knowledge on things such as policy goals and objectives and the policy integration approach. Regarding
this aspect of nutrition, there is only a very general understanding, which is arguably too low to support
policy integration. Based on how people discuss the functionality of the DNCC it can also be concluded
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that they do not feel they have enough time and means to carry out all tasks and responsibilities.
However, the respondents themselves do not link this to a lack of human resources, although it could be
argued that having only one person that has nutrition as its main priority negatively influences this.
Overall people at the district level are quite satisfied with the capacity of human resources and they do
not perceive it to be a major obstacle for working on nutrition.
At sub-county level people are much more critical about human resources. The respondents’ answers
indicate that there are not enough people with sufficient knowledge on nutrition available to do work on
implementing nutrition policies. They describe themselves to have some general knowledge about
nutrition, but do not feel that they know enough details or are prepared to answer questions from the
community (SC-2,3b,4):
‘If I went to a community to create awareness and someone asked me a tough question I wouldn’t answer that
comment.’ (SC-4)
There is no person with specialized knowledge on nutrition at sub-county level and it is no one’s main
responsibility. Human capacity to do work on nutrition is thus very low. Also, as explained above, the
SNCCs have not received any training or orientation. This supports their claim that they feel they have
insufficient knowledge on the topic. The sample of sub-counties does not allow for extensive elaboration
on the possible effects of administrative unit proliferation, as this was not one of the selection criteria.
However, from the interviews it became clear that Bwongyera has recently been split into two units.
Structures there are not in place and people do not feel confident enough about their understanding of
nutrition or their ability to do work related to it. This indicates that administrative unit proliferation can
potentially worsen the situation.
One of the possible effects of this insufficient level of knowledge is that at sub-county level political
attention, leadership and commitment for nutrition are non-existent:
‘The political leadership in almost all sub-counties and town councils looked disinterested in the training as few
chairmen attended these orientations despite being informed and sometimes being at the sub-county bearing the
orientation sessions.’ (SNCC orientation report)
The attitude towards working on nutrition is much more passive and leaders on this topic were not
identified at sub-county level. Although some people do indicate that they understand the importance of
nutrition, it is not a topic that gets widespread attention across the sub-counties. This, in combination
with the dysfunctionality of the SNCCs makes it possible to conclude that attention or commitment are
not present.
At district level human resources are not experienced as an obstacle to policy integration. Although the
available human resources are not perfect on all aspects, especially not on the content of policy
documents, there are no major capacity issues both in terms of number of people and knowledge. The
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presence of NGOs and a nutritionist at district level help to create a sufficient level of knowledge. This
helps to increase the level of policy integration, as it is more likely there is a shared understanding of
the problem of malnutrition and it increases capacity to implement policy instruments. However, a
different picture emerges at sub-county level. Similar to the situation with the orientation of the SNCCs,
the capacity from the district level does not seem to have trickled down to the sub-county level in any
way. There is low capacity both in terms of numbers and in terms of (specialized) knowledge.
Decentralisation is likely to have contributed to this problem in the sense that many people are needed
at each level, and such a large amount of specialized knowledge is not available. Also, resources are not
sufficient to put all these people in place. The case of Bwongyera seems to indicate that administrative
unit proliferation, a phenomenon of decentralisation, worsens the situation.
4.2.3 Consultation of regional actors
The expectation was formulated as follows: it is expected that difficult bottom-up consultation between
government levels in a decentralised system has a negative influence on the policy-design and
implementation processes.
In the processes of policy-making and implementation at higher levels, Uganda strives to use a bottom-
up structure. In an ideal situation, the bottom-up structure works starting from the lowest level and feeds
information from this level into each of the consecutive higher levels. Respondents indicate they prefer
such a structure, as they believe it allows for valuable information to be captured that would otherwise
not be known (D/B-3,4,6,9). However, the question is how consultation of lower level governments
works in practice and what effects this has on policy-design and implementation processes.
At district level, respondents evaluate the use of the bottom-up structure fairly positively. They feel that
they are able to make valuable contributions in delivering local knowledge that central government
officials do not have (D/B-3,4,6,9). However, at the same time respondents indicate that interaction
between the district and sub-county does not take place frequently enough. The district needs to go down
to the sub-counties more often, as more interaction will help the sub-counties to implement activities
better. However, the current financial situation forms an obstacle (D/B-1,5,8; NGO-6). Taking this
finding into account it is not surprising that sub-county officials are much more critical about the
functionality of the bottom-up structure. They argue that local knowledge from the lower government
levels is not sufficiently integrated into the policy-making process. According to them, planning is too
much top-down, without sufficient use of the knowledge and practical experience of the reality on the
ground (SC-1,2,3a,4):
‘Another thing what we need was bottom up planning but for them they plan for us and they don’t know what is on the ground right now.’ (SC-3a)
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The sub-county representatives indicate that they are often ill-informed about and bypassed in the
implementation of nutrition programs in their sub-county. The Uganda Multi-Sectoral Food Security
and Nutrition Program (UMFSNP) is mentioned as an example as this program is directly implemented
in schools and sub-counties do not participate. Some respondents feel that this can create problems of
ownership:
‘Because now the sub-county chiefs look at it, ah it is a district program, let them do what they feel like, no ownership.
So they end up doing whatever they feel like.’ (NGO-8)
As the lower government levels do not feel engaged, they might also not feel responsible for working
on nutrition and their interest in the topic can decrease (D/B-6; NGO-8; SC-1).
At district level, but more so at sub-county level it is recognized that interaction between the two levels
is not ideal. Consultation of regional actors, in this case the interaction between the district and sub-
county, is insufficient both in terms of quantity and quality. The information exchange is limited and it
is highly unlikely that through these ad-hoc interactions all relevant information from lower level
government ends up at the district level as input for policies such as the District Development Plan or
the District Nutrition Action Plan. One of the main argued benefits of decentralisation, which is that
policy making and implementation is improved because information from on-the-ground is available
and accurate, is not realized. Decentralisation is likely to play a role here in a similar way as with the
issues around the orientation of the Sub-County Nutrition Coordination Committees. Because of their
autonomy the government levels are too disjointed and there is no clear organizational structure between
them. Also, the district does not take responsibility to actively engage with the lower levels. This
weakens policy integration because not all relevant input for policy documents is gathered. The policy
instruments and policy goals might therefore not make an ideal fit with the on-the-ground reality. Also,
it can over time lead to diverging frames, especially across levels, as the problem is not necessarily
understood to have the same importance by everyone. Under subsystems the density of interactions
might be lowered, as there is little interaction in the form of consultations. Relevant actors do not
optimally communicate with each other, decreasing information sharing and cooperation between them,
leaving opportunities for further integration of the dimension subsystems untouched. In the worst case
scenario, actors or bodies might even start to refrain from working on nutrition.
4.2.4 Financial structure
The expectation formulated was as follows: It is expected that decentralisation worsens the financial
situation of lower government levels and thereby inhibits a policy integration approach.
As already stated under frames, by far the largest share of the district budget exists of conditional grants,
which are earmarked funds that are transferred from the central to district government. According to
various respondents the high level of dependence on the conditional grants means that the district does
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not have full autonomy. They feel this goes against the idea of a decentralised governance structure and
that in this way the central government holds too much power (D/B-1,3,4,5,8; NGO-2):
‘I think we cannot realise full potential of decentralisation when eighty percent of your funds come from the centre.
Eighty percent of those funds are conditional.’ (D/B-8)
Next to that, the small amount of local revenue that is available is expected to decrease even further over
the fiscal year 2018/2019 as a result of administrative unit proliferation. Within the district, several sub-
counties are split up into two new sub-counties or into a sub-county and a town council. Town councils
do not generate local revenue for the district. Therefore, the amount of local revenue collected will
reduce further (D/B-2,3,4; NGO-6; SC-2). In practice there is thus little opportunity to fund nutrition
activities from the local revenue.
To improve the financial structure, respondents propose two types of solutions. The first type entails all
solutions in which the district gets more funding from the central government over which they can freely
decide (NGO-4; D/B-3). According to them, this would improve the functionality of the decentralised
system and would allow the district to create a bigger nutrition budget. The second type includes
solutions that give the central government more steering power, where this power should be used in a
top-down manner to enforce implementation of a nutrition budget (D/B-2,8; NGO-3; D/P-2). The
respondents that suggest this option see it as the only way to safeguard adequate budget for nutrition,
because it is not given priority in the district. However, respondents do not know how either of these
processes can be set in motion. There is no clarity about whom, at which government level, should take
initiative. Some respondents argue that nutrition needs to be in the budget first before grants can be
received, meaning the process starts at the district level. Others think that first a grant needs to be created
at the central level and only after that this can be included in the budget.
Both the issues with the conditional grants and the local revenue originate from the decentralised
structure and make it impossible for the district to decide on its own priorities. This is also recognized
by the respondents in the sense that they propose alternative solutions to the current system, of which
some would result in a move away from decentralisation. However, the district does not have any other
option than to accept the conditional grants, as without receiving those it is impossible for the district to
function. This structure holds back a high level of policy integration of nutrition policy across
departments. The conditional grants keep the sectoral structure in place and do not allow to work across
sectors. A high level of policy integration for frames, which would include enabling existing structures,
is therefore not reached. Also, the capacities to implement policies are limited and thereby negatively
influence the dimension policy instruments. Without any budget for nutrition, implementation of any
nutrition policy instrument, whether substantive or procedural, is minimal. Overall, the lack of resources
holds back proper integration of nutrition policy across departments.
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4.2.5 Leadership
An influence of decentralisation on policy integration on which no expectation was formulated but
which has been identified as relevant based on the research data is leadership. As explained in section
4.1.2 under subsystems, in the district the chairman has taken up a leadership position with regards to
advocating for improving the nutrition situation in Ntungamo. The decentralised governance system
might explain why he is able to do so and why many people also recognize him as a leader. The district’s
political wing enjoys a large degree of autonomy and theoretically, the district should be able to
prioritize issues it finds most pressing in the local context. Although we have seen that not all structures
needed for this are in place, the large degree of autonomy does support the chairman’s leadership. He
has the right to advocate for the issues he believes to be important, as he is the elected leader of a largely
autonomous government unit, and he uses this to advocate for nutrition. In this way, he can create
political attention for the topic and enhance policy integration through the dimension subsystems.
However, at the same time creating political commitment might be more difficult because of
decentralisation. The national level cannot take the lead in political commitment, because the district
level has a strong say in this. However, with limited budget and strong financial dependence on the
central level, district officials get little space to decide on their own priorities. In this way the ideals of
decentralisation seem to clash with its poor implementation in reality. Decentralisation on one hand
helps to create attention, but on the other hand inhibits further commitment. Although attention is a first
step, the lack of commitment limits the feasibility of policy integration under subsystems, as resources
and structures, such as coordinating bodies, cannot be fully put in place. This also affects the
implementation of policy instruments, and thereby decreases its level of integration.
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CHAPTER 5 – CONCLUSION AND DISCUSSION
5.1 Conclusion
In this research the aim was to answer the following research question: What are the effects of
decentralisation on the policy integration process of nutrition policy at district level in Uganda?. The
analysis done to answer this question consisted of two steps. The first step operationalised the concept
policy integration using the dimensions frames, subsystems, policy goals and policy instruments. The
second step operationalised decentralisation, where four expectations were formulated that guided
identification of possible effects on policy integration.
The most positive aspects of policy integration were found under the dimensions frames and subsystems.
For frames there is a shared understanding of the causes and multi-sectoral nature of malnutrition and
stakeholders believe that multiple departments across the governance system should work on nutrition.
Under subsystems it can be seen that the District Nutrition Coordination Committee (DNCC) is in place,
has an active membership and its roles and responsibilities are clearly defined and well-understood by
stakeholders. Also, there is political attention for and leadership on nutrition. However, for all four
dimensions problems for policy integration were also identified. Issues under frames are that there is no
good understanding of a policy integration approach. Next to that, the existing financial structure inhibits
a policy integration approach. This, in combination with an overall lack of financial resources, makes it
more difficult for policy instruments to be implemented in an integrated manner. The policy instruments
itself can also be improved. Especially the procedural instruments need to be formulated more
specifically and responsibility for them can be allocated more logically. For subsystems to have a high
level of policy integration governance of nutrition should be shared among a larger number of formal
active bodies than just the DNCC. Information sharing and cooperation between actors and bodies
should be geared towards true integration, with a higher density of interactions. For the dimension policy
goals a higher level of coherence between and within policy documents that discuss nutrition needs to
be realized. Overall, the level of policy integration is stuck between low and medium and a high level
of policy integration remains a long distance away.
The effects of decentralisation on policy integration are multiple. The most problematic effect of
decentralisation is that there is very poor interaction between district and sub-county level. District and
sub-county are too disjointed because of their autonomous positions. This has resulted in less on-the-
ground information being available that can be used in processes of policy making and implementation.
Also, because of poor communication and coordination the sub-counties have not put in place the Sub-
county Nutrition Coordination Committees (SNCCs). This limits opportunities for vertical cooperation
and leads to a reduced number of active bodies, thereby decreasing the reach of the governance system
and the density of interactions. The interaction between central and district level seems less problematic,
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but at the same time seems rather minimal. The District Nutrition Coordination Committees (DNCCs)
are in place, but there are indications that NGOs have contributed more to this than the central level
itself. It is therefore questionable how interaction actually takes place between the central level and the
district. Also, the existing financial structure imposed by the central level strongly inhibits any attempts
for policy integration. It forces the district into sectoral structures and leaves it no space to take decisions
autonomously. The only positive effect of decentralisation on policy integration identified is on
leadership. The power that the district chairman enjoys because of decentralisation is helpful for
advocating for nutrition and generating attention for the topic.
Coming back to the question of what the effects of decentralisation are on policy integration of nutrition
policy at district level in Uganda, it can be concluded that most of these effects are negative. The most
significant effects originate from the autonomous position each of the levels has, because of which
coordination between them is difficult. This has a negative influence on horizontal policy integration at
district level, as it shapes the governance system in a way that inhibits addressing the complex problem
of nutrition. This means that decentralisation is a limiting factor in achieving a high level of policy
integration and thus a complicating rather than complimenting factor. To improve future processes of
policy integration of nutrition policy in Ntungamo, hurdles that now exist because of decentralisation
need to be recognised and overcome as to lift nutrition policy to a high level of integration.
5.2 Discussion
In this section, key findings in relation to each of the four expectations are discussed. The relevance of
each of them is evaluated and if diverging results were found, possible explanations are offered. The
most interesting findings are discussed in relation to existing literature and points of future research are
formulated. This will help to tell us more about the relation between decentralisation and policy
integration, about which too much is still unknown. The points of future research therefore aim to isolate
the effect of decentralisation on policy integration as to be able to better determine the exact dynamics
between the two concepts.
The first and third expectation relate to vertical coordination and the ways in which this is influenced
by decentralisation. Both expectations were very relevant in the context of this research and yielded
interesting findings. It was found that vertical interaction between different government levels,
especially the lower levels, is a difficult process which holds back horizontal policy integration. A
relatively strong process of horizontal policy integration at district level does thus not seem to go hand
in hand with strong vertical cooperation between government levels. This finding is supportive towards
the coordination dilemma proposed by Egeberg & Trondal (2015). However, this research finds the
opposite dynamic compared to the research on the European Union. Rather than strong vertical
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coordination and weak horizontal integration, in this research strong horizontal integration is found in
combination with weak vertical coordination. Decentralisation might well be an explanatory factor. In
a decentralised system the government levels are not strongly linked, which might make achieving a
high level of horizontal integration easiest. To be able to draw more general conclusions on the influence
of decentralisation on the coordination dilemma, more research is necessary. By assessing both types of
integration in several case studies, both in decentralised systems and other governance systems, it should
be possible to identify a pattern and isolate the influence of decentralisation. In this way, factors that
explain the underlying dynamics of the coordination dilemma can be revealed.
Another key finding is that a coordinating body has the potential to positively contribute to
various problems raised in both expectation one and three. When functional, a body such as the District
Nutrition Coordination Committee (DNCC) has the potential to establish a clear mandate of the
coordination responsibilities at one government level and to facilitate consultation between levels.
Although the DNCC in Ntungamo is not fully functional, it does stimulate communication between
different stakeholders and in the future could provide a good channel for communication between
government levels. These findings are similar to the case study on Zambia conducted by Drimie et al.
(2014). There is was seen that the existence of a DNCC has created a space for intersectoral
communication and mutual supportive learning and has facilitated the process of building trust between
stakeholders.
The importance of such a body is also recognized in other nutrition policy literature. Acosta & Fanzo
(2012), Harris & Drimie (2012) and Kennedy et al. (2015) all make the argument that coordination is
essential, but that setting up coordinating bodies is challenging. The need for such bodies is widely
recognized and a functional coordinating body is seen as enabling for further progress, but stakeholders
often find it difficult to put such a body in place (Harris & Drimie, 2012; Kennedy et al., 2015). Candel
(2018) points out an interesting observation on coordinating bodies in relation to climate change policy
integration. In this strand of literature it was seen that the level of centralisation affects states’ national
coordinative capacities in the sense that centralised states more often install coordinating mechanisms
at national level compared to decentralised states. In addition to this, Lockwood et al. (2009) point out
that in a decentralised setting regional bodies are important and should have enough power and support
to fulfil their mandates. Whereas in a centralized system it makes sense coordinating bodies are installed
at central level, in a decentralised setting it seems to be just as relevant to do this at a lower government
level. More research is needed to create a better understanding about in what position coordinating
bodies have most added value and how this relates to different types of governance systems. This can
be done by comparing the role of coordinating bodies at different positions in different types of
governance systems. By assessing how much these coordinating bodies contribute to the process of
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policy integration it can be seen in what positions in different governance systems a coordinating body
is most useful to have.
Diving further into the first expectation, which addresses the possible barrier that decentralisation can
be in creating a clear mandate on coordination responsibilities for each horizontal level, more points for
further research are identified. The most interesting finding specific to this expectation was the role of
the Non-Governmental Organisations (NGOs) in the process of setting up and instructing coordinating
bodies. NGOs have provided sensitizations and training on nutrition to coordinating bodies, have helped
to put them in place and provided financial resources. It is therefore questionable whether the
coordinating bodies can function without NGO support. In the Environmental Policy Integration (EPI)2
literature the role of NGOs was not discussed and therefore it was not foreseen that they would be of
significant influence. One explanation for this is that the EPI studies have been conducted primarily in
developed federal states, where NGOs play a less important role in the governance system. Comparing
to the topic and geographical focus of EPI to that of this research, it is more likely that NGOs are
involved in nutrition in developing countries.
Looking at nutrition literature, it can indeed be seen that the role of partner organisations, such as NGOs
and Civil Society Organisations (CSOs) is highlighted in various studies. Acosta & Fanzo (2012)
propose based on the findings in their research that civil society groups are needed for social
accountability mechanisms. However, the findings of this research demonstrate that the role of partner
organisations goes much further than that and is thereby more in line with the hypothesis that Garret et
al. (2011) propose. They argue that partner organisations have strong capacities with which they can
carry out defined responsibilities. In a case study on Zambia, Harris & Drimie (2012) also found that
most programs are implemented by NGOs, because institutional and operational government structures
are too weak. This means that the findings of this research, namely that NGOs are important for
implementation of nutrition, are in line with the wider literature on nutrition policy.
These findings related to NGO activity in the nutrition governance system generate two points for future
research. Firstly, the difference of NGO activity in the nutrition policy field compared to the
environmental policy field gives rise to the question whether the influence of NGOs on policy
integration is specific to nutrition. To gain further insights in this, research should be done on several
topics for which a policy integration approach is used, with specific attention for the role of NGOs.
Secondly, to determine whether the activity of NGOs is more important in a decentralised setting, as
this research suggests, a comparative case study approach can be used. Lower government units with
and without NGO activities, but apart from that with a similar context, have to be selected. This allows
to assess what the differences in the process of integration of nutrition policy are and whether these can
2 When the term EPI literature is used in this discussion it refers to all the literature used in section 2.2.2 to formulate the
expectations on decentralisation
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be explained by different levels of NGO activity. This provides more insight into the importance of
NGOs in relation to policy integration in decentralised governance systems. Also, it yields valuable
information for policy makers and the NGOs themselves, as they can better understand their importance
and power position.
The second and fourth expectation both focussed more on how decentralisation influences the capacities
needed to have a functioning system of policy integration. The second expectation looked at whether
decentralisation has a negative influence on the availability of human resources. In the EPI literature,
on which the expectation is based, as well as nutrition studies such as Drimie et al. (2014) and Lapping
et al. (2014) it is described how a lack of human resources has a detrimental effect on policy
implementation. However, this research did not find the same results. Problems were only found at sub-
county level, although specialized knowledge could also be somewhat improved at district level. Also,
human resources were not found to have a very significant influence on the dimension policy
instruments. The findings do not necessarily oppose the expectation, but human resources are not found
to be of the same level of importance as expected based on existing literature. Availability of specialized
knowledge in the form of a nutritionist and the option for stakeholders to attend trainings might have
had a positive effect on human resources. These are points that can be kept in mind for future research.
Apart from that, there seem to be no direct leads that offer an explanation for these differences in
findings. Since the findings do not completely diverge from other literature the expectation on human
resources does therefore not provide valuable leads for future research.
The fourth expectation discussed the influence of decentralisation on policy integration. In line with the
expectation, and thus EPI and decentralisation literature, it was found that decentralisation negatively
influences the financial situation of lower level governments and thereby inhibits policy integration. As
all the different strands of literature and the findings of this research confirm one another, further
research is unlikely to generate different results and does therefore not have priority. Rather, it would
be more interesting to explore how financial systems in a decentralised governance system can be shaped
in such a way that they facilitate policy integration. Issues such as who is responsible for the budget and
how different government levels or departments can spend it in when working with a collaborative
approach are relevant to look at. Especially for nutrition this is relevant, as it does not fall under one
department, which is a complicating factor. The outcomes of such research can provide suggestions for
concrete improvements on how the financial structure of a decentralised system can be adjusted in such
a way that it supports policy integration of nutrition policy.
The last finding that yields interesting points for future research concerns the essence of leadership. In
this research it was found that decentralisation might have had a positive effect on leadership, because
the leader has a more autonomous position and can therefore more easily determine its own priorities.
In the case of Ntungamo, this was used to actively advocate for nutrition. The importance of leadership
69
is also stressed in most other research on the implementation of nutrition policy. In many cases it is
found that without leadership, it becomes more difficult to implement nutrition policy (Acosta & Fanzo,
2012; Kampman et al., 2012; Kennedy et al., 2015). The only diverging result is research conducted in
Zambia, where there was no significant leadership but yet some progress was made (Drimie et al.,2014;
Harris & Drimie, 2012). However, implementation remains sub-optimal and it could be argued that with
more leadership this would improve. In the literature there thus seems to be consensus that leadership is
important for successful implementation of nutrition policy. However, nothing is known about how it
contributes to policy integration in a decentralised setting, as this is not discussed in EPI literature.
Therefore, a point for further research is to look at whether leadership in a decentralised system has a
different effect on policy integration compared to leadership in a centralised setting. By comparing
leadership in the two different types of governance systems and assess whether they have a different
function or importance, it will be possible to tell more about the role of leadership for policy integration
in decentralised systems.
5.3 Limitations
During this research it was possible to consult a large variety of sources, both in terms of active
stakeholders working on nutrition in the district and by having access to many policy documents. It was
relatively easy to gather data. People were willing to cooperate for interviews and most relevant
documents were shared. The only problem was that district bureaucrats were not always able to locate
certain possibly relevant documents. However, there is no indication that any relevant information has
been withheld from the researcher on purpose.
The sample of respondents in this research is relatively large and contains a variety of stakeholders, but
could have been more complete. During the field work, it was difficult to find the right people to talk to
in the political sphere. A snowball method did not lead to them, as many people could not name whom
from the political sphere would be relevant to talk to. Therefore there is only a small number of
politicians and there is no full insight into the process of policy integration from a political point of view.
Another limitation of the respondent sample is the small number of sub-counties. It does give a first
image of the dynamics at sub-county level in relation to the district level and with the use of selection
criteria there is a higher possibility that certain differences are observed. However, as there is only one
sub-county for each of the categories, coincidences cannot be distinguished from trends. Therefore, this
part of the research will mainly result in recommendations for future research and some first insights
into the coordination dilemma.
The order of the interviews is another point that can unintendedly have influenced the process of data
gathering. Roughly, the order in which the interviews were conducted was district bureaucrats, NGOs
and sub-counties. As all respondents were consulted once, findings could not be verified or further
70
investigated. This means that there was no possibility to follow up on some interesting leads. Also, the
answers given in the first interviews can have steered data gathering in a certain direction, thereby
possible forgetting other relevant topics. It was tried to avoid this by following the interview script and
ensuring that all topics were covered in all interviews.
In hindsight, not all sub-counties selected were the best cases for each of the boxes in the matrix.
However, none of the sub-counties that were originally selected moved from one box to another based
on the information that became available during the research. Therefore, the sub-county selection did
still have the potential to provide insight in factors that could influence vertical coordination. Not many
differences between the sub-counties were found. The only difference found was that in two sub-
counties, there was some sort of coordinating structure in place, whereas this was not the case in two
other sub-counties. However, neither of these two sub-counties committees seemed to be very functional
and this difference was therefore not significant. On other topics, such as human resources, no significant
differences were found between the sub-counties. This means that in next research, the relevance of the
selection criteria that were used for sub-county selection should be evaluated and possibly adjusted.
Lastly, the language and cultural barrier were limitations. Although a translator was not necessary, the
level of English of respondents differed. In some cases questions were simplified or rephrased, which
can stand in the way of exploring the full depth of the topic. Cultural differences can also influence
interpretation of the answers given, because misunderstanding on the value of comments made might
arise. Overall, this can lead to interpretation on the researcher’s side that are different from the meaning
intended by the respondent.
5.4 Recommendations for Policy Makers
There are four concrete recommendations for policy makers in Ntungamo to improve the nutrition
situation in their district. Firstly, a permanent budget for nutrition should be created in the district budget
workplan. To create this budget, the district will have to engage with the decentralised financial system
and explore possibilities. Either local revenue can be used, or initiative needs to be taken to lobby for
such a budget at central level, possibly in cooperation with NGOs. When this budget is secured, it will
ensure continuity and stability for nutrition activities over the coming years and will allow for easier
collaboration across departments. The budget should be used to support the District Nutrition
Coordination Committee (DNCC), which has the potential to grow further into its role as a true
coordination and communication mechanism. With this money investments could be made in human
resources for more permanent management of the DNCC. This is the easiest way to strengthen its
structure and ensure daily management of all its responsibilities.
Secondly, the coherence within and between policy documents should be improved. Objectives should
be streamlined between different documents and for each objective, clear strategies and interventions
71
need to be formulated. All relevant sectors should be included and made responsible for successful
execution of these interventions. Specific attention needs to be paid to procedural instruments, which
need to be specific and feasible. Also, they should encourage for work to be done across departments,
so that policy integration becomes much easier to do. The DNCC should get more power to support
coordination between departments so that these instruments are successfully implemented.
Thirdly, the commitment of politicians in Ntungamo towards nutrition should be improved to increase
the chance of successful policy integration. As stated under leadership for subsystems, politicians are
essential to generate commitment and ensure sufficient resources. When they do not have a high enough
level of knowledge, as is arguably the case, they might not fully realize the importance of nutrition for
overall development. Further sensitization will increase the chance that they become more supportive
of the cause. This will hopefully make it possible to move from mere political attention to wide political
commitment, thereby further enabling the entire district governance structure to do more work on
improving the nutrition situation.
Lastly, the district should engage more actively with lower level government, specifically sub-counties.
By engaging more actively with vertical coordination structures and fulfilling all of its responsibilities,
the district can help to activate the coordination bodies at sub-county level. This makes it more likely
that the sub-counties will provide valuable input from on-the-ground to processes of policy making and
implementation. It will improve the functionality of the governance system as a whole, as various
governance levels are then more actively and coherently involved in nutrition integration processes,
which will increase the level of policy integration.
72
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APPENDICES
Appendix 1: Interview list
The codes on the interview list indicate the sub-groups to which the different respondents belong. This is the
total number of interviews per sub-group:
- District Bureaucracy: 9
- NGO representative: 8
- District Political: 3
- Sub-county: 5
- Other: 1
# Code Respondent type Date Duration
(in min)
1 D/B-1 District Bureaucracy 01-08-2018 65
2 D/B-2 District Bureaucracy 02-08-2018 55
3 D/B-3 District Bureaucracy 06-08-2018 55
4 D/B-4 District Bureaucracy 07-08-2018 30
5 D/B-5 District Bureaucracy 07-08-2018 40
6 D/B-6 District Bureaucracy 09-08-2018 60
7 D/B-7 District Bureaucracy 09-08-2018 40
8 NGO-1 NGO Representative 14-08-2018 55
9 NGO-2 NGO Representative 15-08-2018 60
10 NGO-3 NGO Representative 17-08-2018 55
11 NGO-4 NGO Representative 17-08-2018 40
12 O-1 CSO 20-08-2018 50
13 D/B-8 District Bureaucracy 20-08-2018 45
14 NGO-5 NGO Representative 21-08-2018 65
15 NGO-6 NGO Representative 22-08-2018 50
16 D/P-1 District Political 23-08-2018 30
17 D/B-9 District Bureaucracy 27-08-2018 60
18 NGO-7 NGO Representative 28-08-2018 45
19 D/P-2 District Political 29-08-2018 55
20 NGO-8 NGO Representative 30-08-2018 40
21 D/P-3 District Political 06-09-2018 40
22 SC-1 Sub-county – Ihunga 27-08-2018 55
23 SC-2 Sub-county – Bwongyera 05-09-2018 65
24 SC-3a Sub-county – Nyakyera 28-08-2018 35
25 SC-3b Sub-county – Nyakyera 07-09-2018 35
26 SC-4 Sub-county – Kayonza 04-09-2018 50
Average 50
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Appendix 2: Interview script
Introduction:
- Introduction researcher + project
o Introduction letter
- Interview is recorded
o The recording is used to type up the interview, will only be used by the researchers
and is not spread.
- Informed consent form
o Explain + sign
- Verify findings at the end of research
General Questions:
- What is your job exactly, specifically in relation to nutrition?
- How would you describe the problem of nutrition in Ntungamo district?
- Does nutrition as a problem receive enough attention in Ntungamo district?
- What are the most important policy documents/guidelines etc you use in the field of nutrition
in Ntungamo district?
note: not all questions have to be asked in the interview and the questions are not necessarily asked in
this order. If other relevant points come up, questions outside of this script may be asked.
DISTRICT LEVEL
Political will
- What do politicians know of nutrition?
- Do they support the nutrition message?
Policy Frames
- Are there specific bylaws formulated on nutrition in the district/sub-county?
o Do you think that the formulation of (more) bylaws on nutrition could help to improve
the nutrition situation?
Policy Goals
- What are the most important policy goals on nutrition in the district/sub-county?
- Are the targets (in the annual workplans) set useful to achieve the goals on nutrition?
o Do you think the targets are realistic?
o Do you think the timeframe in which the targets are set are realistic?
Sub-system involvement
Often overlap with questions on the DNCC
- Can you list for me the most important stakeholders working on nutrition in Ntungamo?
Specifically for NGOs – continuation on this:
o Which other NGOs are active on nutrition in the district?
o Can you explain me how you work together with the government actors on the topic
of nutrition?
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o Whom at the district office do you have contact with about the implementation
activities you do related to nutrition?
o Do you work together with the DNCC and if so, how?
- Are all actors equally active on nutrition or are some doing more work than others?
- Is there a clear role division among the different actors working on nutrition policy?
- Do all actors working on nutrition have enough knowledge about nutrition? If not, what are
some things they do not know about?
- Is communication and information sharing between the different actors going well?
o Do the different sectors work together well? Is there a true multi-sectoral approach or
are the sectors still working independently?
Policy instruments
- What do you think are the most important things that need to be done to improve nutrition in
the district/sub-county?
o What sort of actions need to be undertaken?
o Which actions work best to improve nutrition?
- What are the problems you encounter when implementing nutrition policies?
o Problems with different types of capacities: staff, knowledgeable/skilled staff,
financial resources, other resources
o How could they best be solved?
Decentralisation
- Relation with national level
o How much freedom do you have to decide on your own priorities within the district?
- Relation with sub-county level – description of this relation
o Are there certain sub-counties that are more or less successful in working on
nutrition? If so, what are the differences between these sub-counties?
o What policy documents is a sub-county supposed to have on nutrition?
o Is there good cooperation between the district and the different sub-counties on the
topic of nutrition? → what are possible problems/difficulties?
o How much freedom do sub-counties have in deciding on their own actions on
nutrition? Do they make use of this freedom?
- How does the formation of new TCs and sub-counties affect the implementation of the
projects and plans on nutrition?
o Does the formation of e.g. new SNCCs go smoothly?
- Budgets (fiscal aspect)
o How do you fund your nutrition activities?
o Where does this funding come from?
o How much freedom do you have in deciding how you spend the funding you receive?
People in DNCC
- What do you think, in an ideal situation, should be the core functions of the DNCC?
o Is the DNCC at the moment capable of carrying out these core functions?
- Can you name for me the most important actors in the DNCC?
- Do you think that the DNCC includes all stakeholders important for nutrition or are there too
many or too few?
- Are there certain actors within the DNCC that take the lead or are more or less active
compared to other actors?
- What are some of the obstacles the DNCC encounters in its daily work?
79
- In what ways do you think the DNCC has contributed to improving the nutrition situation in
Ntungamo over time?
People not in the DNCC
- Are you familiar with the DNCC and its work?
- Can you explain to me what the DNCC does?
- Do you think the DNCC affects nutrition policy implementation?
SUB-COUNTY LEVEL
Decentralisation
- How do you think you do on nutrition compared to other sub-counties in Ntungamo district?
- Relation with the district
o Is there a good cooperation between the sub-county and the district on the topic of
nutrition? → what are possible problems/difficulties?
o Do you give input for the district development plan/nutrition action plan? If so, is this
input used well by the district?
▪ Do you know who you need to go to if you want to give policy input?
o Can you decide on your own priorities related to nutrition within the sub-county?
▪ Do your policy goals differ compared to those of the district? If so, how?
▪ Do you have the freedom to adjust policy targets for your specific sub-
county?
o Does the district help you in any way, if so how? Or do they make your work more
difficult?
- Budgets
o How do you fund your nutrition activities?
o Where does this funding come from?
- Do the politicians here in the sub-county support your work?
o If so, in what ways?
o If not, what could they do to support your work better?
- Stakeholders:
o Which people are important for nutrition activities here in the sub-county?
o Does everyone that work on nutrition know enough about the problem?
End interview
- Thanks for cooperation
- Possible to approach you again for some questions
- Any relevant policy documents you can send to me?
- Any other people that you think would be good for me to talk to?
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Appendix 3: Overview of documents acquired during fieldwork
Type of document Name of document
Council minutes
District Council
- 02.2016
- 05.2016
- 01.2018
Sub-committee op Health, Education and Children Affairs
- 08.2017
Ntungamo Policy Documents - Ntungamo District Development Plan 5 year FY 2015/16-2019/20
- Ntungamo District Nutrition Action Plan
- Ntungamo Multi-Sectoral Nutrition Action Plan Midterm Review report District Nutrition Coordination
Committee meeting minutes
- 26 June 2018
- 10 May 2018
- 24 November 2017
- 20 October 2017
- 7 February 2017
- 14 November 2016
- 13 July 2016
- 11 June 2015
Other District Nutrition
Coordination Committee
documents
- Ntungamo district start up action plan for nutrition coordination
committees 2017/18
- SNCC orientation report
Ntungamo work plans - Annual work plan 2016/17
- Annual workplan 2017/18
- Annual workplan 2018/19
Ntungamo performance reports - Performance contract 2015-2016
- Performance report 2015-2016 Q1
- Performance report 2015-2016 Q2
- Performance report 2015-2016 Q4
- Performance report 2016-2017 Q1
- Performance report 2016-2017 Q2
- Performance report 2016-2017 Q3
- Performance report 2016-2017 Q4
- Performance report 2017-2018 Q1
- Performance report 2017-2018 Q2
- Performance report 2017-2018 Q3
Other financial documents
Ntungamo
- Approved budget estimates 2018/19
- Ntungamo Performance contract 2015-2016
Other - Activity report on follow up on nutrition action plan development
Note: documents were only included in this overview when they were used in the research. More documents
were found during fieldwork, but these were irrelevant and therefore not included in this overview.
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Appendix 4: Overview of full list of codes used for data analysis
Conditional Grants
Conditional Grants - Flexibility
Decentralisation
Decentralisation - administrative unit proliferation
Decentralisation - central/district
Decentralisation - District/Sub-county
Decentralisation - funding
Decentralisation - policy design
DNCC
DNCC - barriers/limitations
DNCC - goals
DNCC - improvements
DNCC - members
DNCC - members activeness
DNCC - members roles
DNCC - tasks
Financial resources - district
Financial resources - limitations
Financial resources - origin
Financial resources - sub-county
Financing nutrition activities
Legal structure - Design bylaws
Legal Structure - Existence bylaws
Legal structure - Implementation bylaws
Multi-sectoral approach - cooperation
Multi-sectoral approach - cooperation district and NGOs
Multi-sectoral approach - Information Sharing
Multi-sectoral approach - sector/actor involvement
Multi-sectoral approach - understanding
Policy Documents Nutrition - Central Level
Policy Documents Nutrition - district level
Policy implementation - improvements
Policy Implementation - problems
Policy implementation - strengths
Political Attention
Political Commitment
Problem Perception - Agriculture
Problem Perception - Community Issues
Problem Perception - Feeding practices
Problem Perception - Food Sale
Problem Perception - Gender
Problem Perception - Health
Problem Perception - Nutrition Knowledge of Population
Problem Perception - Other
Problem Perception - Poverty
Role NGOs
SNCC - functionality
Sub-county - capacity
System-wide commitment
UMFSNP
Use of evidence
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Appendix 5: Overview financial structures Ntungamo District
Type of
funding ↓
2015/2016 2016/2017 2017/2018 (1)
Approved
budget
Cumulative
receipts
end of Q4
%
realized
Approved
budget
Cumulative
receipts
end of Q4
%
realized
Approved
budget
Cumulative
receipts
end of Q3
%
realized
Locally
raised
revenues
1,273,950 666,967 52 1,273,949 908,662 71 1,380,399 704,028 51
Discretionary
government
transfers
3,918,802 4,502,780 115 4,154,425 4,139,751 100 4,323,826 3,409,533 79
Conditional
government
transfers
26,818,338 26,638,579 99 31,470,384 31,022,370 99 33,375,598 25,024,343 75
Other
government
transfers
2,135,799 1,126,858 53 806,149 580,953 72 806,149 594,117 74
Donor
funding
2,940,000 956,785 33 4,713,478 232,842 5 2,786,932 142,577 5
Total 37,086,889 33,891,969 42,418,385 36,884,578 42,672,904 29,874,598
All amounts are in Ushs thousands (1): the Q4 data were not published yet at the time of data gathering. Therefore, data from Q3 are used.
If 100% realisation is to be reached in Q4, the realisation at the end of Q3 should be around 75%. This
data therefore gives a good indication of what level of realisation will be reached at the end of Q4. This table shows the realisation of the approved budget for one fiscal year. The Ugandan fiscal year
runs from 1 July to 30 June the next year. The fiscal year is divided into four quarters (Q), which are
the following: • Quarter 1: July, August, September
• Quarter 2: October, November, December
• Quarter 3: January, February, March
• Quarter 4: April, May, June
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Appendix 6: Overview attendance DNCC meetings3
Position
↓
Date
meeting
→
26-06-
2018
10-05-
2018
24-11-
2017
20-10-
2017
07-02-
2017
14-11-
2016
13-07-
2016
11-06-
2015
03-2015
(4)
# meetings
attended
(total 9)
DAO X X X X X X X X X 9
District Statistician X X X X X X X X 8 SEO X X X X X 5
SAEO X X X X X X X 6
SHE X X X X 4 IoS X X X X X 5
SPO X X X 0 X X X 6
CDO 0 (1) X (1) X 2 ADHO (2) 0 X X X 0 X 0 X 2x (3) X 6
DFO X X X 3
ACAO X X X X X X X X 8
Nutritionist X X 0 0 X X 0 X X 6
ARISE X X X X 4
TPO X X 2 SASAKAWA X 1
SNV YOBA X X 2
Red Cross X X X X 4 Aprocel X X X X 4
RHITES X 1
Religious rep. X X X 0 3 UMFSNP 0 X 1
OWC X 1
IA X X 2 DPU X 1
Ag.DNRO 0 X 0 X 2
Sub-county chief X 1 Unidentified X 1
Total attending: 15 21
12
10
7
8
8
11
8
X = present
0 = absent with apologies
(1): CDO was from the sub-county of Itojo
(2): most times this is the assistant DHO on maternal and child health
(3): during this meeting 2 ADHOs were present: ADHO maternal and child health and ADHO environmental
health
(4): this was the meeting to finalize the nutrition document, it is not clear whether this was an official DNCC
meeting.
Abbreviations and departments (if applicable) - DAO: district agricultural officer (production)
- SEO: senior education officer (education)
- SAEO: Senior assistant engineering officer (works and technical services)
- SHE: senior health educator (health)
- IoS: Inspector of Schools (education)
- SPO: senior probation officer (community development)
- CDO: community development officer (community development)
- ADHO: assistant district health officer (health)
- DFO: district financial officer (finance)
- ACAO: assistant chief administrative officer
- OWC: Operation Wealth Creation program
- IA: Internal Auditor
3 The attendance lists were all retrieved in the process of document gathering. For some attendance there is no full clarity
which position in concerns, because different abbreviations are used or attendance lists are difficult to read. With help from
people familiar with the local system and persons in the system the researcher tried to ensure that the attendance of all
different positions were reported on correctly, but this cannot be fully guaranteed.
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- DPU: District Project Unit
- Ag.DNRO: District Natural Resource Officer
ARISE, TPO, SASAKAWA, SNV YOBA, Red Cross, Aprocel, RHITES and UMFSNP are all organisations
that are implementing (nutrition) programs in Ntungamo district.