Evolution of Nutrition Policy in Senegal Andrea L. Spray ANALYSIS & PERSPECTIVE: 15 YEARS OF EXPERIENCE IN THE DEVELOPMENT OF NUTRITION POLICY IN SENEGAL Evolution of Nutrition Policy in Senegal June 2018 Andrea L. Spray Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal © 2018 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank and the Cellule de Lutte Contre la Malnutrition (CLM; Nutrition Coordination Unit of the Government of Senegal) with other external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. Responsibility for the content of this work lies solely with the author or authors. 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Examples of components can include, but are not limited to, tables, figures, or images. All queries on rights and licenses should be addressed to the Bureau Exécutif National de la Cellule de Lutte contre la Malnutrition (BEN / CLM), Rue 07 Point -E - BP 45001 Dakar – Fann, Sénégal; tél : 33 869 01 99; fax: 33 864 38 61; e-mail: ben@clm.sn. Cover photo: Adama Cissé/CLM Cover design: The Word Express, Inc. Acknowledgments T his report was written by Andrea L. Spray, Nutrition Consultant with the World Bank. Spe- cial appreciation goes to Dr Guelaye Sall (Professor of Pediatrics, University of Dakar) for his early draft on which this report is largely based. The author is greatly indebted to the authors and curators of the many historical documents that have chronicled Senegal’s fight against malnutrition over time and through its various stages. Reviewers. We are grateful to all reviewers of the reports of the series—Elodie Becquey (IFPRI), Patrick Eozenou (World Bank), Dominic Haazen (World Bank), Derek Headey (IFPRI), Abdou- laye Ka (CLM), Jakub Kakietek (World Bank), Ashi Kohli Kathuria (World Bank), Christine Lao Pena (World Bank), Biram Ndiaye (UNICEF), Jumana Qamruddin (World Bank), Claudia Rokx (World Bank). They each generously dedicated their time and effort, and their invaluable input played an important role in the evolution of the series. Partners. We would also like to give thanks to the following members of the task force of development partner organizations, who provided guidance on the conceptualization, implementation and finalization of the series: Sophie Cowpplibony (REACH), Aissatou Dioum (UNICEF), George Fom Ameh (UNICEF), Julie Desloges (Government of Canada), Aida Gadiaga (WFP), Laylee Moshiri (UNICEF), Aminata Ndiaye (Government of Canada), Marie Solange N’Dione (Consultant), and Victoria Wise (REACH). Client. Finally, our greatest appreciation is extended to the dedicated staff of the CLM, whose work is chronicled in the series, and the thousands of health workers and volunteers who are daily delivering life-saving nutrition services to vulnerable populations throughout Senegal. This work was conducted under the guidance of Menno Mulder-Sibanda (Task Team Lead and Senior Nutrition Specialist, World Bank). The series was prepared by a team led by Andrea L. Spray (Consultant). Aaron Buchsbaum (World Bank) supported publishing and dissemination, along with Janice Meerman (Consultant) and Laura Figazzolo (Consultant). Information regard- ing the financial support for the series is provided at the end of the report. About the Series T he government of Senegal, through the Cellule de Lutte contre la Malnutrition (Nutrition Coordination Unit) (CLM) in the Prime Minister’s Office is embarking on the development of a new Plan Stratégique Multisectoriel de Nutrition (Multisectoral Strategic Nutrition Plan) (PSMN), which will have two broad focus areas: (1) expanding and improving nutrition ser- vices; and (2) a reform agenda for the sector. The reform agenda will include policy reorientation, governance, and financing of the PSMN. The PSMN will discuss the framework and timeline for the development of a nutrition financing strategy, which will require specific analysis of the sector spending and financial basis, linking it to the coverage and quality of nutrition services. Senegal is known for having one of the most effective and far-reaching nutrition service delivery systems in Africa. Chronic malnutrition has dropped to less than 20 percent, one of the lowest in continental Sub-Saharan Africa. Government ownership of the nutrition program has grown from US$0.3 million a year in 2002 to US$5.7 million a year in 2015, increasing from approximately 0.02 percent to 0.12 percent of the national budget. Yet, these developments have not led to enhanced visibility of nutrition-sensitive interventions in relevant sectors such as agriculture, education, water and sanitation, social protection, and health. The absence of nutrition-sensitive interventions in the relevant sectors, combined with the recent series of external shocks, has favored continued fragmentation of approaches, discourse, and interventions that address nutri- tion. In addition, there is no overall framework for investment decision making around nutrition, which puts achievements made to date in jeopardy. Meanwhile, nutrition indicators are stagnat- ing and other issues with major implications (such as low birth weight, iron deficiency anemia, maternal undernutrition, and acute malnutrition) have received little or no attention. A review of policy effectiveness can help raise the importance of these issues, including house- hold and community resilience to food and nutrition insecurity shocks, as a new priority in nutrition policy development. This series of analytical and advisory activities, collectively entitled Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal (“the se- ries”), aims to support the government of Senegal in providing policy and strategic leadership for nutrition. Further, the series will inform an investment case for nutrition (The Case for Investment in Nutrition in Senegal) that will: (1) rationalize the use of resources for cost-effective interven- tions; (2) mobilize actors and resources; (3) strengthen the visibility of nutrition interventions in different sectors; and (4) favor synergy of interventions and investments. The series was produced with guidance from a task force of development partner organizations under the leadership of the World Bank, and in close collaboration with the CLM. The task force comprised representatives from the following organizations: Government of Canada, REACH, UNICEF and the World Bank. Documents in the series: Report Description Nutrition Situation in Senegal An analysis of the nutritional status of key demographic groups in Marc Nene Senegal, including the geographic and sociodemographic inequalities in nutrition outcomes and their determinants. Evolution of Nutrition Policy in An historical analysis of the nutrition policy landscape in Senegal, Senegal including the evolution of nutrition policies and institutions and Andrea L. Spray their respective implications for programming and prioritization of interventions. Political Economy of Nutrition An analysis of the policy and political levers that can be used Policy in Senegal in Senegal to foster government leadership and galvanize the Ashley M. Fox intersectoral coordination needed to mainstream nutrition into government policies and programs, and effectively, efficiently, and sustainably deliver nutrition interventions. Nutrition Financing in Senegal An analysis of the allocated funding to nutrition interventions in Marie-Jeanne Offosse N. Senegal from 2016 to 2019, estimates of budgetary capacity for financing nutrition by government, and estimated costs for selected high-impact interventions. Capacities of the Nutrition Sector An analysis of the organizational and institutional capacities for in Senegal addressing nutrition in Senegal, covering the CLM, key ministries, and Gabriel Deussom N., Victoria other stakeholders contributing to improvements in nutrition at the Wise, Marie Solange Ndione, central, regional, and local levels. Aida Gadiaga Cost and Benefits of Scaling Up Analysis of the relative costs and effectiveness of alternative scenarios Nutrition Interventions in Senegal for scaling up nutrition interventions in Senegal over the five years Christian Yao covering the PSMN. Risks for Scaling Up Nutrition in Analysis of the potential risks to the scale-up of nutrition in Senegal, Senegal their likelihood of occurrence, potential impact, and potential mitigation Babacar Ba measures. A Decade of World Bank Support The World Bank Independent Evaluation Group Project Performance to Senegal’s Nutrition Program Assessment Report, which evaluates the extent to which World Bank Denise Vaillancourt operations supporting nutrition in Senegal from 2002–14 achieved their intended outcomes and draws lessons to inform future investments. Acronyms Acronym English Acronyme Français AEC Community Executing Agency AEC Agence d’Exécution Communautaire AEN Essential Nutrition Actions AEN Actions Essentielles en Nutrition AGETIP Executing Agency for Public AGETIP Agence d’Exécution des Travaux Works and Employment d’Intérêt Public AGIR Global Alliance for Resilience AGIR Alliance Globale pour la (AGIR)—Sahel and West Africa Résilience (AGIR)—Sahel et Afrique de l’Ouest BANAS Office for Food and Applied BANAS Bureau National d’Alimentation Nutrition in Senegal et de la Nutrition Appliquée au Sénégal BCC Behavior Change CCC Communication de Changement Communication de Comportement BEN National Executive Bureau BEN Bureau Exécutif National BER Regional Executive Office BER Bureau Exécutif Régional CANAS Committee of Food and CANAS Comité d’Analyse Nutritionnelle et Nutritional Analysis in Senegal Alimentaire au Sénégal CIFF Children’s Investment Fund CIFF Fondation du Fonds Foundation d’Investissement pour l’Enfance CLM Nutrition Coordination Unit CLM Cellule de Lutte contre la Malnutrition CMAM Community Management of PCMA Prise en Charge Communautaire Acute Malnutrition de la Malnutrition Aiguë CNLM National Committee for the Fight CNLM Commission Nationale de Lutte Against Malnutrition contre la Malnutrition CNSA National Food Security Council CNSA Conseil National sur la Sécurité Alimentaire COSFAM Senegalese Committee for Food COSFAM Comité Sénégalais pour la Fortification Fortification des Aliments en Micronutriments CREN Center of Recovery and CREN Centre de Récupération et Nutritional Education d’Education Nutritionnelle CRS Catholic Relief Services CRS Catholic Relief Services CTC Community Therapeutic Care STC Soins Thérapeutiques Communautaires Acronym English Acronyme Français CTIUS Technical Committee for CTIUS Comité Technique pour l’Iodation Universal Salt Iodization Universelle du Sel DAN Division of Food and Nutrition DAN Division de l’Alimentation et de la Nutrition DANSE Division of Food, Nutrition and DANSE Division de l’Alimentation de la Child Survival Nutrition et de la Survie de l’Enfant DBM Double Burden of Malnutrition DFM Double Fardeau de la Malnutrition DHS Demographic and Health Survey EDS Enquête sur la Démographique et la Santé DPNDN National Policy for the DPNDN Document de Politique Nationale Development of Nutrition de Développement de la Nutrition DSE Division of Child Survival DSE Division de la Survie de l’Enfant DSRP Poverty Reduction Strategy DSRP Document de Stratégie de Paper Réduction de la Pauvreté ECD Early Childhood Development DPE Développement de la Petite Enfance FAO Food and Agriculture FAO Organisation des Nations Unies Organization of the United pour l’Alimentation et l’Agriculture Nations GAIN Global Alliance for Improved GAIN Alliance mondiale pour Nutrition l’amélioration de la nutrition GDP Gross domestic product PIB Produit Intérieur Brut GIE Microenterprises GIE Groupement d’Intérêt Economique GNP Gross national product PNB Produit National Brut HKI Helen Keller International HKI Helen Keller International ICN International Conference on CIN Conférence Internationale sur la Nutrition Nutrition ICN2 Second International Conference CIN2 Deuxième Conférence on Nutrition Internationale sur la Nutrition IDD Iodine Deficiency Disorder IDD Troubles liés à la carence en iode IEC Information, Education and EIC Education, Information et Communication Communication IFPRI International Food Policy IFPRI Institut international de recherche Research Institute sur les politiques alimentaires Acronym English Acronyme Français ILO International Labor Organization OIT Organisation Internationale du Travail IMF International Monetary Fund FMI Fonds Monétaire International ITA Food Technology Institute ITA Institut de Technologie Alimentaire LPDN Nutrition Policy Letter LPDN Lettre de Politique de Developpement de la Nutrition MDG Millennium Development Goals OMD Objectifs du Millénaire pour le Développement MI Micronutrient Initiative MI Micronutrient Initiative NASAN New Alliance for Food Security NASAN Nouvelle Alliance pour la Sécurité and Nutrition Alimentaire et Nutritionnelle NEPAD New Partnership for Africa’s NEPAD Nouveau Partenariat pour le Development Développement de l’Afrique NESA Child Food and Nutrition Security NESA Nutrition Enfant et Sécurité Alimentaire NETS Child Targeted Nutrition and NETS Nutrition Ciblée sur l’Enfant et les Social Transfers Transferts Sociaux NGO Nongovernmental Organization ONG Organisation Nongouvernementale OCCGE Coordination and Cooperation OCCGE Organisation de Coordination et Organization for the Control of de Coopération pour La Lutte the Major Endemic Diseases contre les Grandes Endémies ORANA Research Organization for Food ORANA Office de Recherches sur and Nutrition in Africa l’Alimentation et la Nutrition Africaine ORSTOM Office for Scientific and Technical ORSTOM Office de la Recherche Research Overseas Scientifique et Technique Outre- Mer PAIN Package of Integrated Nutrition PAIN Paquet d’Activités Intégrées de Actions Nutrition PASAV Food Security Support for PASAV Projet d’Appui à la Sécurité Vulnerable Households Project Alimentaire des Ménages Vulnérables PCIME Integrated Management of PCIME Prise en Charge Intégrée des Childhood Illness Maladies de l’Enfant PCIME-C Community Integrated PCIME-C Prise en Charge Intégrée Management of Childhood des Maladies de l’Enfant Illnesses Communautaire PDC Communal Development Plan PDC Plan de Développement Communal Acronym English Acronyme Français PDEF Ten-Year Education and Training PDEF Programme Décennal de Program l’Education et de la Formation PECMA Community Management of PECMA Prise en Charge Communautaire Acute Malnutrition de la Malnutrition Aiguë PINKK Integrated Nutrition Project in PINKK Projet Intégré de Nutrition dans les Kolda and Kédégou Regions Régions de Kolda et de Kédougou PIUS Universal Salt Iodization Program PIUS Programme d’Iodation Universelle du Sel PLW Pregnant and Lactating Women FEA Femmes Enceintes et Allaitantes PNC Community Nutrition Project PNC Projet de Nutrition Communautaire PNDL National Program for Local PNDL Programme National de Development Développement Local PNDS National Health Development PNDS Plan National Développement Plan Sanitaire et Social PNIA National Agriculture Investment PNIA Programme National Program d’Investissement Agricole PNSE Child Survival Strategic Plan PNSE Plan National de Survie de l’Enfant PPNS Nutrition and Health Protection PPNS Programme de Protection Program Nutritionnelle et Sanitaire PQDES Quadrennial Economic and PQDES Plan Quadriennal de Social Development Plan Développement Economique et Social PODES Policy Plan for Economic and PODES Plan d’Orientation pour le Social Development Développement Economic et Social PRF Program for the Enhancement of PRF Programme de Renforcement de Fortification la Fortification PRN Nutrition Enhancement Program PRN Programme de Renforcement de la Nutrition PSD-CMU Health Coverage Strategic Plan PSD-CMU Plan Stratégique de Développement de la Couverture Maladie PSMI/PF Maternal and Child Health and PSMI/PF Programme de Santé Maternelle Family Planning Program et Infantile et de Planification Familiale PSMN Multisectoral Strategic Nutrition PSMN Plan Stratégique Multisectoriel de Plan la Nutrition SAM Severe Acute Malnutrition MAS Malnutrition Aiguë Sévère Acronym English Acronyme Français SANAS Nutrition and Food Service of SANAS Service de l’Alimentation et de la Senegal Nutrition Appliquée du Sénégal SBCC Social Behavior Change CCCS Communication pour le Communication Changement de Comportement Social SDG Sustainable Development Goals ODD Objectifs de Développement Durable SMART Standardized Monitoring and Enquêtes Enquêtes Suivi et évaluation Survey Assessment of Relief and SMART Standardisés des Urgences et Transitions Survey Transitions SNAN National Service of Food and SNAN Service National de l’Alimentation Nutrition et de la Nutrition SUN Scaling Up Nutrition Movement SUN Mouvement pour le Renforcement de la Nutrition UNDP United Nations Development PNUD Programme des Nations Unies Programme pour le Développement UNESCO United Nations Educational, UNESCO Organisation des Nations Unies Scientific and Cultural pour l’Education, la Science et la Organization Culture UNICEF United Nations Children’s Fund UNICEF Fonds des Nations Unies pour l’enfance URO- Oral Rehydration Unit—Center URO- Unité de Réhydratation Orale— CREN of Recovery and Nutritional CREN Centre de Récupération et Education d’Education Nutritionnelle USAID United States Agency for USAID Agence des États-Unis pour le International Development Développement International USI Universal Salt Iodization IUS Iodation Universelle du Sel WFP World Food Programme PAM Programme Alimentaire Mondial WHA World Health Assembly AMS Assemblée Mondiale de la Santé WHO World Health Organization OMS Organisation Mondiale de la Santé ZACH Zinc Alliance for Child Health ZACH Programme Alliance Zinc pour de la santé de l’enfant Unless otherwise indicated, child nutrition indicators referenced in this report are taken from the UNICEF- WHO-World Bank Joint Child Malnutrition Estimates1. Contents Executive Summary 1 Introduction 5 Building the Foundation (1950s–1970s) 9 Curative Approach (1970s–1990s) 15 Institutionalization of Nutrition (1990s–2000s) 21 Intensification and Decentralization (2000s–2010s) 29 Multisectoral Approach (2010s) 39 Conclusion 43 Appendix A – Senegal Nutrition Policy Timeline 45 Endnotes 51 References 55 List of Boxes Box 1: Nutrition-Related Policies and Influences during the Building the Foundation Generation 13 Box 2: Nutrition-Related Policies and Influences during the Curative Approach Generation 20 Box 3: Nutrition-Related Policies and Influences during the Institutionalization of Nutrition Generation 27 Box 4: Nutrition-Related Policies and Influences during the Intensification and Decentralization Generation 38 Box 5: Nutrition-Related Policies and Influences during the Multisectoral Approach Generation 42 List of Figures Figure 1: Stunting of Children Under Five in Senegal, 1992–2014 19 Figure 2: Wasting of Children Under Five in Senegal, 1992–2014 19 Figure 3: Organogram of PNC 23 Figure 4: Organogram of PRN 31 Photo: Adama Cissé/CLM xii Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal Executive Summary W ith a 46 percent reduction in under-five Building the Foundation (1950s–1970s). By Sene- stunting, from 34.4 percent in 1992 to 19.4 gal’s independence in 1960, food and nutrition security percent in 2014, Senegal has witnessed was already a high-level priority, and stable leader- one of the biggest rates of improvement in the fight ship over four decades helped to keep it so. During against undernutrition in the world and currently has this generation, in 1961, the first Plan Quadriennal de one of the lowest rates of stunting in Sub-Saharan Af- Développement Economique et Social (Quadrennial rica. How was this achieved and what contributions Economic and Social Development Plan) (PQDES) did various nutrition policies make over time? The pur- prioritized improving food and nutrition security, de- pose of this report is to provide an historical overview fined women and children as a vulnerable group, and of nutrition policies in Senegal, including analysis of budgeted resources for food and nutrition research. the nutrition policy landscape, the evolution of nutrition Major institutions were established with long-term im- policies and institutions, and their implications for pro- portance for nutrition. Facility- and community-based gramming and prioritization of interventions. nutrition programs and nutrition-sensitive agriculture and social protection programs were being imple- Nutrition policy in Senegal has evolved over a series mented, albeit at small scale. Facility-based nutrition of distinct generations, defined here as: building the programs, to the extent they existed, focused on cu- foundation (1950s–1970s); the curative approach rative care and food distribution. Nutrition services (1970s–1990s); institutionalization of nutrition during this period were decidedly not integrated, but (1990s–2000s); intensification and decentralization rather a patchwork of isolated and, arguably, ineffec- (2000s–2010s); and multisectoral approach (2010s). tive initiatives. Senegalese food consumption surveys Six factors have been identified as crucial to the suc- dating from 1946 indicated widespread micronutrient cess of each generation: (1) nutrition championship; and protein deficiencies; nationally representative nu- (2) institutional ownership; (3) multisectoral coordi- trition data were not available until 1986. nation and collaboration; (4) community ownership; (5) integrated services and delivery platforms; and Curative Approach (1970s–1990s). During this gen- (6) partner engagement. eration, Senegal lost social and economic ground. Evolution of Nutrition Policy in Senegal 1 The Sahelian drought (1968–74) was Senegal’s first Concurrently, the Commission Nationale de Lutte con- postindependence large-scale environmental crisis. In tre la Malnutrition (National Committee for the Fight 1979, Senegal adopted a series of structural adjust- Against Malnutrition) (CNLM) was created in the Pres- ment reforms, supported by the World Bank and the ident’s office with a mandate to ensure the availability International Monetary Fund (IMF), aimed at reduc- of a safety net for the poor and responsibility for over- ing the state’s role in the economy. Formal nutrition sight of PNC. The nutrition objective of PNC was to policy during this generation was still primarily articu- prevent the deterioration of nutrition among the most lated in national documents of reference. Senegal was vulnerable in targeted poor urban areas. However, ahead of the global curve in articulating in national PNC was as much a youth employment operation as policy the nascent global understanding of the impor- it was a nutrition intervention. PNC was innovative for tance of nutrition and the causes and consequences contracting young people for the management, train- of malnutrition. However, the 1977 Food Investment ing, delivery, and supervision of preventive nutrition Strategy for achieving these goals was criticized for services at the community level. Ultimately, although failing to address the key drivers of malnutrition. By PNC was a popular project because it delivered nutri- 1980, Senegal’s health infrastructure was in shambles tional services and much-needed employment in urban and suffering from lost credibility. Coordination and areas, it suffered from severe challenges with target- delivery of nutrition services in Senegal during this ing, cost, coordination, quality, and corruption. During period was weak and remained focused primarily on this period, there was a slight decrease in stunting, facility-based curative care and food supplementation from 34.4 percent in 1992 to 29.5 percent in 2000. targeted at urban centers. Despite increasing efforts to reach vulnerable populations with nutrition services, Intensification and Decentralization (2000s–2010s). rates of stunting continued to increase considerably. The newly elected Wade administration promoted a more progressive approach to economic development Institutionalization of Nutrition (1990s–2000s). characterized by a more pluralistic environment, pro- Gross domestic product (GDP) per capita in Sene- motion of the private sector, and greater emphasis gal at this time was still in decline, over two-thirds of on the development of human capital. Nutrition was the population was living below the poverty line, and understood to be a critical component of human devel- Senegal’s economic and social indicators were poor, opment, and President Abdoulaye and First Lady Wade even in comparison to neighboring countries and were visible nutrition champions. In 2001, the Cellule low-income countries generally. Then, in 1994, struc- de Lutte Contre la Malnutrition (the Nutrition Coordina- tural adjustment reforms of the 1980s culminated in tion Unit) (CLM) was created to replace the CNLM; the a sudden devaluation of the CFA franc, imposed by institutional home for nutrition was henceforth moved the IMF. The consequence was rapid inflation, de- to the Prime Minister’s Office. The Bureau Exécutif terioration of food and nutrition security, and urban National (the National Executive Bureau) (BEN) was unrest, particularly among young urban professionals. created as part of the CLM to be the permanent exec- National nutrition policy during this period was, in ef- utive office in charge of day-to-day management and fect, defined by whatever nutrition programs were in the implementing agency responsible for executing place. However, during this period, operationalization the new World Bank-funded Programme de Renforce- of nutrition intervention was granted to the Agence ment de la Nutrition (Nutrition Enhancement Program) d’Exécution des Travaux d’Intérêt Public (Executing (PRN). Nutrition was also added as a distinct invest- Agency for Public Works and Employment) (AGETIP). ment line in the national budget. The Lettre de Politique AGETIP had no prior experience in health or nutrition de Développement de la Nutrition (Nutrition Policy programming, but it was the institutional home of the Letter) (LPDN) defined—for the first time—national newly started World Bank-funded Projet de Nutrition nutrition policy and set out appropriate strategies for Communautaire (Community Nutrition Project) (PNC). programming and monitoring. PRN operates through 2 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal multilevel and multisectoral collaboration across par- spending—is also increasing. In 2015, the Document de ticipating ministries, nongovernmental organizations Politique National de Développement de la Nutrition (Na- (NGOs), the private sector, local government, and the tional Policy for the Development of Nutrition) (DPNDN) community. Indicators were established against which outlined a new vision. The Plan Stratégique Multisecto- progress was measured, including nutrition practices, riel de la Nutrition (Multisectoral Strategic Nutrition Plan) coverage of nutrition services, and nutrition knowl- (PSMN)—currently under development—will operation- edge. From 2000 to 2012, stunting dropped from 29.5 alize the DPNDN and be the principal tool for nutrition percent to 19.2 percent. These results were achieved coordination going forward. PRN continues to be Sene- at significantly lower cost than under PNC. gal’s flagship nutrition program. Multisectoral Approach (2010s). The end of 2015 In 2014, President Sall launched the Emerging Sene- marked the end date of the Millennium Development gal Plan with the goal of taking Senegal to emerging Goals (MDGs); Senegal had mixed results. Progress country status by 2035 through improving the well-be- against hunger was nil: 24.5 percent in 1991 and 24.6 ing of the population and guaranteeing access to percent in 2015. However, during the period of the social services. Senegal cannot achieve emerging MDGs, stunting decreased a remarkable 44 percent, country status without continued improvement in from 34.4 percent in 1992 to 19.4 percent in 2014. This nutrition. Evidence available at the launch of the Sus- singular achievement has solidified Senegal’s place tainable Development Goals (SDGs) indicates that as a global leader in nutrition policy. The transition in progress toward new nutrition targets has stalled and leadership from President Wade to President Macky Senegal is considered to be “off course.” Needed are Sall in 2012 closed a chapter in which nutrition policy more pronutrition interventions through other sectors; benefitted from unusually high political visibility. Global improved targeting to identify areas of highest burden; recognition has translated into increased funding for nu- and increased efforts to extend services to hard-to- trition in Senegal; the government financial commitment reach areas. To meet World Health Assembly (WHA) to nutrition—both in total and as a proportion of nutrition and SDG goals, more financial resources are needed. Evolution of Nutrition Policy in Senegal 3 Photo: Adama Cissé/CLM 1 Introduction Rationale. Nutrition has been ingrained in key so- including analysis of the nutrition policy landscape, cial and economic development policies in Senegal the evolution of nutrition policies and institutions, and since the birth of the Republic. The evolution of nutri- their implications in terms of programming and prior- tion policy—and its impact on the state of nutrition in itization of interventions. In so doing, the report aims Senegal—is the result of a constant interplay between to provide context to future nutrition investment and social, environmental, and economic events; politics; the PSMN currently under development, and to inform the state of nutrition knowledge; and the engagement the decision-making process at this critical juncture. and influence of external stakeholders. Nutrition policy Here, “policy” refers to all guidance for the manage- also encompasses what actually gets implemented; ment of nutrition—be it effective (everyone does it) or therefore, it is also influenced by available capacity ineffective (it never leaves the paper it is written on), and resources at all levels. With a 46 percent reduc- formal (written and adopted) or informal (unwritten in- tion in under-five stunting, from 34.4 percent in 1992 to stitutional behaviors and practices). The timeline of just over 19.4 percent in 2014, Senegal has witnessed nutrition policies and related initiatives is provided in one of the biggest rates of improvement in the world appendix A. and currently has one of the lowest rates of stunting in West Africa. This success has put Senegal in the Overarching Trends. Nutrition policy in Senegal has spotlight, and other countries, especially those in evolved over a series of distinct generations,2 defined Francophone Sub-Saharan Africa, look to Senegal as here as: building the foundation (1950s–1970s); the a model for nutrition intervention. Indeed, in the global curative approach (1970s–1990s); institutionalization fight against malnutrition, more often than not Senegal of nutrition (1990s–2000s); intensification and decen- has been ahead of the curve—in a position of inform- tralization (2000s–2010s); and multisectoral approach ing global advocacy initiatives—not just a beneficiary (2010s). These are briefly summarized below. The of the global evidence base. remainder of the report describes the evolution of nu- trition policy by generation and its intersection with Objective. The purpose of this report is to provide projects and programs, institutions, global and region- an historical overview of nutrition policies in Senegal al initiatives, social and political events, and nutrition Evolution of Nutrition Policy in Senegal 5 knowledge and advocacy. For each generation, the trition interventions conspicuously failed to improve report also discusses the following six themes of par- nutrition status. ticular relevance to the evolution of nutrition policy in Senegal and arguably factors crucial to its success: Deepening understanding of the causes and conse- (1) nutrition championship; (2) institutional owner- quences of malnutrition—and the highly visible failure ship; (3) multisectoral coordination and collaboration; of early nutrition projects to achieve results—ushered (4) community ownership; (5) integrated services and in the institutionalization of nutrition generation delivery platforms; and (6) partner engagement. (1990s–2000s). This generation was marked by a reorientation toward a preventive approach through in- tegrated intervention packages and community-based Nutrition Policy Generations interventions in an effort to “do things better” for nutri- tion. This generation also witnessed the entry of the First was the building the foundation generation World Bank into financing for nutrition in Senegal. A (1950s–1970s), preindependence to the Sahelian change in institutional ownership of nutrition during drought. During this generation, global knowledge this period would prove to be a major turning point and about malnutrition, how it manifests and its short- and signaled the politicization of nutrition policy. long-term consequences, was in its nascent stage. Interventions to address malnutrition—especially at The intensification and decentralization genera- scale—were virtually unheard of, although nutritional tion (2000s–2010s) is delineated by the election of rehabilitation and food distribution were carried out. President Abdoulaye Wade, the subsequent creation Notable about this generation is that nutrition already of the CLM and launch of PRN, and Senegal’s eventu- had visibility at the highest levels at the launch of al joining of the Scaling Up Nutrition (SUN) Movement. the Republic in 1960. This is evidenced most strong- It was a decade of action for nutrition that turned the ly by the first (1961), second (1965) and third (1969) tide for nutrition policy in Senegal with rapid improve- PQDES, which among other things, established a se- ment in nutrition outcomes. For the first time, Senegal ries of institutions dedicated to food and nutrition and developed a national nutrition policy and instituted a codified maternal and infant protection as national coherent multisectoral approach to improving nutrition priorities. with a dedicated budget line. Strong political support during the Wade administration, combined with con- Next was the curative approach generation certed effort fueled by the race to reach the MDGs, (1970s–1990s), marked by growing awareness of resulted in securing widespread improvements in the importance and extent of malnutrition in Senegal, stunting, firmly placing Senegal in the national and largely in response to the Sahelian drought, and the global spotlight. This period also witnessed the emer- first large-scale nutrition emergency response proj- gence of the first serious efforts at nutrition-sensitive ects to address it. Implemented with the support of interventions in Senegal. global partners, these initial forays into large-scale in- tervention planted seeds of nutrition infrastructure that The current multisectoral approach generation would evolve and be strengthened over subsequent (2010s) commenced with the transition from President decades. During this period, nutrition interventions Wade to President Macky Sall in 2012, and Sene- primarily involved identification and treatment of cas- gal’s assuming a position of prominence as a global es of acute malnutrition, despite mounting evidence leader in nutrition intervention. National leaders have of the multisectoral determinants of malnutrition, the leveraged achievements in the dramatic reduction of importance of early preventive intervention, and the malnutrition to increase financing for nutrition, includ- long-term consequences of malnutrition for human ing through government resources. New evidence development. As a result, these early large-scale nu- demonstrating the limitations of nutrition-specific inter- 6 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal ventions alone for improvement in stunting, combined are on the horizon. Evidence available at the launch with unprecedented levels of cross-sectoral commit- of the SDGs indicates that progress against new nu- ment and collaboration, have redoubled the focus on trition targets has stalled, and Senegal is considered nutrition-sensitive interventions in key sectors. Efforts to be “off course.” Senegal cannot achieve emerging are underway to define the future for nutrition policy in country status without continued improvement in nutri- a Sall administration determined to achieve emerging tion. If Senegal hopes to benefit from its hard-fought country status by 2035. gains, achieve its goals, and maintain its position as a global leader in nutrition intervention, then increased The evolution of nutrition policy and its impact on nutri- decentralization and ownership among regional and tion outcomes have earned Senegal global recognition, local authorities fueled by enhanced investments are but serious challenges remain and new global threats required. Evolution of Nutrition Policy in Senegal 7 Photo: Adama Cissé/CLM 2 Building the Foundation (1950s–1970s) Preindependence to the Sahelian drought Nutrition Context tion de Coordination et de Cooperation pour Ia Lutte contre les Grandes Endémies (Coordination and Senegal. To understand the evolution of nutrition poli- Cooperation Organization for the Control of the Ma- cy in Senegal and how Senegal came to be a leader in jor Endemic Diseases) (OCCGE). Although ORANA nutrition intervention, it is important to recognize that and OCCGE covered the former colonies of French by the time of independence several important nutri- West Africa,4 in practice ORANA functioned as a tion-related inroads had already been made. Dakar’s reference center on nutrition for the entire Sahel re- history as the capital of the Federation of French West gion, undertaking research in the science of nutrition Africa from 1895 to 1958 solidified Senegal’s position biochemistry, disease, treatment, and surveillance. early on as a seat of regional authority for nutrition and ORANA is perhaps most notable for creating the first other issues. Senegal gained independence in 1960 African food composition table. More germane to this and had just two presidents, both from the Socialist report, however, through partnerships with ORANA Party, in forty years until 2000. Food and nutrition se- and several universities, Senegal trained a cadre of curity was a high-level priority at the outset, and stable nutrition specialists, a valuable resource uncommon leadership helped to keep it so. Moreover, the first among other African nations at the time, that would decentralization reforms were made in 1964, laying contribute to the championing of nutrition in Senegal the foundation for what would ultimately become the for decades to come. platform for multisectoral coordination of nutrition ac- tivities at the local level. The West African Conference on Nutrition and Child Feeding, sponsored by the U.S. Agency for Interna- Global and Regional. In 1956, prior to indepen- tional Development (USAID), with representatives dence, the Office de Recherches sur l’Alimentation from thirteen West African countries and participation et la Nutrition Africaine (Research Organization for from UN agencies (Food and Agricultural Organiza- Food and Nutrition in Africa) (ORANA)3 was estab- tion (FAO), World Health Organization (WHO), and lished by the French and based in Dakar. Since 1961, UNICEF), OCCGE, and ORANA, was hosted in ORANA has operated as an institute of the Organisa- Dakar in 1968, with welcoming remarks made by Evolution of Nutrition Policy in Senegal 9 future president (then–Minister of Planning and In- which unequivocally established nutrition as a nation- dustrial Development), Abdou Diouf. The conference al priority. proceedings focused on factors related to “the perma- nent conditions of undernourishment,” including the The first PQDES prioritized the improvement of food “apparently unrelated disciplines such as agriculture, and nutrition security through rural cooperatives and economics, food technology and education” (Republic assistance to farmers, established women and chil- of Senegal and USAID 1968). The conference pro- dren as a vulnerable group, and budgeted resources ceedings are remarkable for providing insight into the for food and nutrition research, including creation of understanding of the causes and consequences of the Institute de Technologie Alimentaire (Food Tech- malnutrition at that time, as well as the perspective of nology Institute) (ITA), which thrives to this day. The world leaders on the importance, and effective means, second PQDES in 1965 further developed nutrition of intervention. infrastructure and capacity in Senegal by creating a discrete nutrition unit5—the Bureau National d’Alimen- In his welcoming remarks, Abdou Diouf attested to tation et de la Nutrition Appliquée au Sénégal (Office the importance of political will and government owner- for Food and Applied Nutrition in Senegal) (BANAS)— ship of nutrition and stated that “no amount of foreign and making ORANA responsible for training a cadre of aid can replace the effort of each nation concerned young African nutritionists. The third PQDES in 1969 to confront nutrition problems as they exist in each signaled increased high-level political commitment to country and to develop and consolidate a concrete nutrition-related outcomes by codifying, as the first policy aimed at their solution.” (Republic of Senegal priority action in urban areas, prevention of child mor- and USAID 1968) The keynote address by the Sen- tality, and, as the second priority action in rural areas, egal Director of Rural Animation and Expansion, Ben maternal and infant protection. Mady Cisse, noted that “healthy nutrition has be- come a medical and social problem at the same time, Institutions. During this generation, two major in- and … the solution capable of bringing results to these stitutions were forged with long-term importance for problems can be found only within the framework of nutrition. First is ITA, a research institute created by multidisciplinary collaboration.” (Republic of Senegal the first PQDES and established in 1963 to direct and and USAID 1968). coordinate research on the treatment, transformation, and use of local food products. During this period, Senegal was already exploring food fortification and Nutrition Policy production of nutrient-dense supplemental foods to address nutrition deficiencies and determining how to Policies. This generation elaborated policies and cre- produce them cheaply enough to be accessible and ated institutions that would lay the foundation for and affordable to the most vulnerable segments of soci- codify the prioritization of maternal and child health ety. Through many iterations and with the support of in Senegal, with far-reaching ramifications for nu- partners such as FAO and USAID, ITA’s mission to- trition. Starting in 1954, prior to independence, the day remains applied food science: generating added Maternity Leave Regulation guaranteed cash bene- value to locally produced foods through processing fits, health protections, and employment security for and quality assurance to improve food and nutrition women working in the formal sector for a period of 14 security and increase exports. Second was BANAS, weeks, and explicit protections for breastfeeding and which, situated within the Ministry of Health and So- against onerous physical labor. Of key importance is cial Affairs (referred to throughout this series as the the role played over the course of Senegalese his- Ministry of Health),6 was responsible, in collaboration tory by national documents of reference in defining with ORANA and ITA, for coordinating and intensifying nutrition policy, starting with the first PQDES in 1961, action against food and nutrition deficiencies through 10 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal development, dissemination, and oversight of norms small-scale community-based nutrition projects and for nutrition service delivery. health promotion interventions. For instance, there is some indication that a more preventive approach Programs. Until the 1970s, historical records of the was taken by rural day care centers (Mehra, Kurz and health and nutrition landscape in Senegal are sparse Paolisso 1992). These centers were implemented by but it is reported that, in 1939, there were only 3 hospi- the education sector (through the Department of Ani- tals, 4 medical centers, 42 maternity hospitals, 10 rural mation Rurale, Promotion Humaine) with support from consultation centers, and several leprosaria (UNESCO NGOs and were nominally responsible for delivering 1964). By the end of the 1970s, with the support of nutrition education through cooking demonstrations, WHO and the International Labor Organization (ILO), “not only for mothers but for all women who, through Senegal had trained hundreds of students in medicine, their families, are involved in the growth of children” midwifery, pediatrics, social work, economics, and nurs- (Republic of Senegal and USAID 1968). Some of ing. Although facility- and community-based nutrition these projects evolved into platforms for delivery of programs and nutrition-sensitive agriculture and social routine health services such as immunizations; how- protection programs were being implemented, records ever, their primary purpose was to provide a safe place from this time indicate that they were carried out on a to keep children from six months to five years of age small scale with limited impact on nutrition outcomes. while their caregivers worked in the fields.8 Although a historically significant early foray into nutrition-sensi- Facility-based nutrition programmes, to the extent they tive intervention, these and other preventive initiatives existed, fell under the supervision of the Ministry of were of limited scope and coverage. Health and focused on curative care and food distribution through Unites de Rehydration Orale—Centres de Récu- Other innovative nutrition-sensitive interventions were peration et d’Education Nutritionnelle (Oral Rehydration carried out at this time through the agriculture and Units—Centers of Recovery and Nutritional Education) social protection sectors, albeit also at small scale. (URO-CRENs). Typically, a Centre de Récuperation et Spurred by efforts to improve food and nutrition securi- d’Education Nutritionnelle (Center of Recovery and Nu- ty and using the latest evidence from nutrition science, tritional Education) (CREN) was a ward or small area of projects implemented during this period aimed to in- a health facility or hospital dedicated to the treatment crease production diversity through agriculture and of children with Severe Acute Malnutrition (SAM). URO- nutrition education and behavior change communica- CRENs treated SAM cases with dehydration caused by tion (BCC). A mass media campaign supported by the severe diarrhea. Less commonly, a CREN might be a U.N. Educational, Scientific and Cultural Organization separate facility managed by an NGO or faith-based or- (UNESCO) encouraged the Senegalese population ganization. These nutrition activities had high visibility, to be “producers as well as consumers” (Republic of addressed an immediate need, and were effective in Senegal and USAID 1968). Education sessions were garnering political support. In practice, however, CRENs facilitated by trained animatrices,9 community volunteer were often unable to provide substantive care because promoters of health, agriculture, and human develop- of shortages of required therapeutic products (such as ment, through rural expansion centers, with technical milk-based F75 and F100) resulting from insufficient support from Maternal and Child Protection, BANAS, financial resources, supply chain mismanagement, or Health Education and Home Economics. Small-scale perishability; lack of trained medical staff; or negligence school feeding and gardening programs were also on the part of health workers. implemented, as were model villages integrating agri- culture and nutrition education and activities. Recognition of the limitations of facility-based curative care and the importance of both adequate quantity and Although efforts aimed at ameliorating malnutrition quality of food in the diet7 prompted implementation of were primarily focused on kwashiorkor and micronu- Evolution of Nutrition Policy in Senegal 11 IMPACT trient deficiencies, records from this time remarkably Institutional Ownership. Records hint at high-level already indicate concern in urban areas of “the so-called debate around the institutional arrangements for nu- prestige foods” and evidence of “disturbing incidence trition and the distinct roles for delivery of nutrition of obesity,” going so far as to note “Coca-Cola could be services versus coordination of nutrition interventions the ruin of some of our States.” (Republic of Senegal across sectors.10 The politics of nutrition were ev- and USAID 1968). It is a testament both to the emerg- idently already in play. Senegal’s first documents of ing discrepancies in nutrition between rural and urban reference delegated BANAS, in the Ministry of Health, populations of Senegal and to the awareness, at least as the institutional home for nutrition, with the support among nutrition experts, of these evolving trends. and collaboration of ITA and ORANA. Despite politi- cal commitment to nutrition, institutionally the nutrition unit was situated too low in the Ministry to influence Key Themes the key decision-making processes (with respect, for example, to budgets, human resources, policies, and By the 1970s, many of the key hallmarks of Sene- programs) that would improve nutrition policy. gal’s nutrition policy were in place. Early attempts at nutrition intervention drew attention to challenges that Multisectoral Coordination and Collaboration. By would be addressed only in later decades. 1968, there was already understanding of the impor- tance of multisectoral coordination in the fight against Nutrition Championship. Political commitment to malnutrition and the role played by key sectors.11 Even nutrition was high from the start of the Republic, evi- at this early period, nutrition curative care delivered by denced by its prioritization in the first PQDES, creation the health system was supplemented by various iso- of an institutional home for nutrition and support for lated nutrition-sensitive interventions, including school nutrition programming albeit at small scale, and state- gardening, school feeding, nutrition education and use ments made by leaders at high-level regional events. of mass media to promote behavior change, and ef- The technical dialogue around nutrition in Senegal forts to involve the private sector and industry in the at this time was sophisticated, reflecting a deep un- production of nutritious foods. derstanding among national leaders of the causes and consequences of malnutrition. Investment in the Community Ownership. Although Abdou Diouf boldly development of the next generation of nutrition spe- asserted in 1968 that, “the essential infrastructure of cialists would prove to have far-reaching implications the country was established and put into the hands for the evolution of nutrition policy. of the citizens” (Republic of Senegal and USAID 12 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 1968), community-based nutrition services during this trition outcomes. The number of children with SAM that period were nascent. Small animation, or sensitiza- could be treated in these centers was low and bore al- tion, projects operated at the community level with most no relation to the number of children with SAM in trained volunteers delivering agriculture and nutrition the community. Preventive nutrition activities carried out education and BCC, and in some projects mothers during this period were also spotty and uncoordinated. coordinated among themselves to run nurseries for agriculture workers. Although these initiatives were Partner Engagement. Partnerships have been in- carried out on a small scale, their results would contrib- tegral to Senegal’s success in improving nutrition ute to the global evidence base for community-based outcomes. Partner engagement even during this early nutrition programming and form the foundation for lat- period is evidenced by the strong research relationship er, more comprehensive, projects. with ORANA, the investment of donors such as FAO and USAID to build nutrition capacity through training Integrated Services and Delivery Platforms. Nutrition programs, and the involvement of USAID and the UN services during this period were decidedly not integrat- agencies in the West Africa Infant and Child Feeding ed, but rather a patchwork of isolated and, arguably, conference hosted by Senegal in 1968. ineffective initiatives. The Ministry of Health, supported by international partners, delivered nutrition curative The key nutrition-related policies and influences for care through CRENs, which had a limited effect on nu- this generation are listed in box 1. BOX 1: Nutrition-Related Policies and Influences during the Building the Foundation Generation Policies Programs • Maternity Leave Regulation (1954) • CRENs (beginning in the 1960s) • 1st PQDES (1961) • Decentralization reforms (1964) Key National Influences • 2nd PQDES (1965) • Dakar as the capital of French West Africa • 3rd PQDES (1969) (1895–1958) • Independence (1960) Institutions • ITA (1963) Key Regional and Global Influences • BANAS (1965) • ORANA (1956) • West African Conference on Nutrition and Child Feeding (1968) • Sahelian drought (1968–74) Evolution of Nutrition Policy in Senegal 13 Photo: Adama Cissé/CLM 3 Curative Approach (1970s–1990s) Growing awareness of the importance and extent of malnutrition in Senegal, largely in response to the Sahelian drought and the first large-scale nutrition emergency response projects to address it Nutrition Context the average for Sub-Saharan Africa and other low-in- come countries. Senegal. The Sahelian drought, which began in 1968 and continued through 1974, was Senegal’s Global and Regional. Notwithstanding Senegal’s first postindependence large-scale environmental difficulties, the 1970s–1990s was a hugely important crisis. Beginning in 1979, Senegal adopted a series historical era in the field of nutrition globally, producing of structural adjustment reforms, supported by the groundbreaking work, such as the UNICEF framework World Bank and the IMF, aimed at reducing the state’s for the multisectoral conceptualization of nutrition, the role in the economy. These reforms curtailed public Iringa project (1983–88) in Tanzania, which demon- expenditures, especially in health and education. strated the potential of community-based nutrition This period also witnessed Senegal’s first transfer programming to improve nutrition outcomes, and a slew of power, from President Léopold Sédar Senghor to of international agreements related to improving child President Abdou Diouf. Despite President Diouf’s ap- nutrition and health. Chief among these with particular parent support for nutrition, evidenced by his remarks relevance to nutrition were the Alma Ata Declaration at the West African Conference on Nutrition and Child in 1978, which solidified international commitment to Feeding in 1968, the combined effect of the drought the importance of primary health care; the Interna- and restricted social services resulting from economic tional Code of Marketing of Breastmilk Substitutes in reforms had serious consequences for social welfare 1981, which prescribed restrictions on the marketing and major repercussions for health and nutrition. By of breastmilk substitutes to ensure that mothers would 1980, international partners were predicting sharp not be discouraged from breastfeeding; the Innocenti decreases in nutrition security (USAID 1980). During Declaration on the Protection, Promotion and Support this period, Senegal indeed lost social and economic of Breastfeeding in 1990, which further recognized ground; by 1994, Senegal had one of the lowest levels breastmilk as the ideal source of nutrition for infants of gross national income among lower-middle-income and promoted exclusive breastfeeding for the first four countries, and social indicators compared poorly with to six months; and the World Summit for Children in Evolution of Nutrition Policy in Senegal 15 1990, which marked the largest gathering of world Having a food and nutrition strategy marked an import- leaders in history and resulted in the Declaration on ant step in the progression of nutrition policy in Senegal; the Survival, Protection and Development of Children however the Food Investment Strategy was deeply crit- and Plan of Action. Together these initiatives firmly es- icized for not addressing what were believed to be the tablished nutrition as a matter of global concern and key drivers to malnutrition: “[T]here is far more concern galvanized international momentum for action. with reducing the burden of foreign exchange earnings imposed by imported cereals, especially rice, than on improving diets or preventing their deterioration over Nutrition Policy time” (USAID 1980). In particular there was concern that the Food Investment Strategy did nothing to ad- Policies. Formal nutrition policy during this generation dress preharvest hunger, believed by some international was still primarily articulated in national documents of stakeholders to be a major contributor to malnutrition in reference. Of chief importance was the 4th PQDES in Senegal. More generally, it was agreed by all stakehold- 1973, which described the nutrition situation in Sen- ers that the data required to diagnose and strategically egal, linked malnutrition to child infectious diseases, address the problem of nutrition were lacking. highlighted poor maternal education and weaning practices as key contributors to malnutrition, and rec- The 6th PQDES, too, marked a substantive departure ognized malnutrition as an important factor in child from business as usual in public health policy with im- mortality. To a degree, Senegal was ahead of the glob- plications for nutrition. It prioritized provision of primary al curve in articulating in national policy the nascent health care services, including integrated maternal and global understanding of the importance of nutrition, and child health and family planning programs, upgrading the causes and consequences of malnutrition. The 4th the network of basic health services, and promoting PQDES established the objectives of Senegal’s first public health care in rural areas. Chief among the ob- large-scale nutrition project, the Programme de Pro- jectives was to reestablish the credibility of the public tection Nutritionelle et Sanitaire (Nutrition and Health health system. However, in 1986 the first Demographic Protection Program) (PPNS). An amendment made in and Health Survey (DHS) for Senegal was published, 1975 to address the growing impact of the drought put indicating—after over a decade of nutrition program- in place the Programme Santé Sécheresse, comple- ming—a nearly 30 percent prevalence of under-three mentary programming to benefit vulnerable groups. stunting. Persistently high rates of malnutrition were attributed to poor execution and corruption of PPNS.12 Subsequent PQDES—the 5th PQDES in 1977, the 6th Consequently, in 1989, under severe criticism, PPNS PQDES in 1981, and the 7th PQDES in 1985—collec- was closed in the 8th Plan d’Orientation pour le tively signaled a substantive shift in food and nutrition Développement Economic et Social (Policy Plan for policy in Senegal toward integrated interventions and, Economic and Social Development) (PODES). In its programmatically, would all reinforce PPNS. In par- place, the 8th PODES launched the Programme de ticular, the objectives of the 5th PQDES included (1) Réhabilitation et de Surveillance Nutritionnelle (Nutri- increasing food supplies to compensate for seasonal, tional Rehabilitation and Surveillance Program) and regional, and socioeconomic deficiencies; (2) improving the Programme de Santé Maternelle et Infantile et de and extending nutritional education; (3) developing and Planification Familiale (Maternal and Child Health and distributing a Senegalese weaning food; (4) consider- Family Planning Program) (PSMI/PF). ation of an iron fortification program; and (5) detailed food consumption surveys, particularly in areas of wide- Also relevant to nutrition policy were decentralization spread malnutrition. The Food Investment Strategy reforms adopted in 1972 that granted greater power 1977–1985 was created by the Ministry of Rural Devel- to the regions, fostered the creation of regional and opment and Water Resources to achieve these goals. local participatory structures, and created a new ad- 16 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal ministrative unit—the “rural community”—consisting of of a millet-flour bread, pain-mi-blé, as a part of a several villages within a radius of 10 kilometers. Under government policy to increase consumption of decentralization, rural communities determined how millet, research in storage and preservation of sta- tax proceeds would be used. Much of the proceeds ple foods, development of supplemental weaning went toward community health activities, such as the foods, and research exploring the potential of soy- construction of maternities and pharmacies and the beans as a cash crop. training of midwives and community health workers. ®® ORANA continued to conduct food and nutrition re- Rural communities thereby provided, for the first time, search and nutrition status surveys in Senegal and the institutional framework for extending the health other West African countries in collaboration with system to the village level. the Office de la Recherche Scientifique et Tech- nique Outre-Mer (Office for Scientific and Technical Institutions. Along with the shift in nutrition policy Research Overseas) (ORSTOM). came a major institutional reorganization. Records ®® CANAS was established in 1979 under the Minis- indicate that in 1979, the Ministry of Health was re- try of Plan and Cooperation as a coordinating body organized in an attempt to help it better support the in the design and implementation of policies and government’s primary health care policies by integrat- programs “to solve the country’s food problems” ing curative and preventive health care; decentralizing (USAID 1980). It included representatives from technical support functions; creating an in-service the Ministries of Finance and Economic Affairs; training capability; and improving the coordination and Plan and Cooperation; Rural Development; Public planning of the entire system ultimately to strengthen Health; and the Secretaries of State from Promotion local services (World Bank 1982). The key nutrition-re- Humaine; Specialized Research and Technique; lated institutions at the time remained BANAS, ITA, and Women’s Affairs. and ORANA, in addition to a newly created coordi- nating body, the Comite d’Analyse Nutritionnelle et By 1980, Senegal’s health infrastructure was in sham- Alimentaire au Sénégal (Committee of Food and Nu- bles and suffering from lost credibility: “Out of 36 tritional Analysis in Senegal) (CANAS). health centers, only 24 were considered operational and 17 were currently in need of repair. About half of Under the reorganization, Senegal’s 492 health posts are also in poor operating condition. Many health centers are 30 to 50 years old. ®® BANAS remained responsible for all nutrition is- Basic commodities, such as water, latrines and elec- sues and services at the national level. Specifically, tricity are unavailable. Technical equipment is missing during this period BANAS was the institutional home or in disrepair; laboratory facilities are poor or non-ex- for PPNS and other nutrition projects carried out by istent” (World Bank 1982). At the same time, and as ORANA, was responsible for the nutrition educa- a result of new decentralization reforms, village-level tion component of PSMI/PF, and published several services, such as rural maternities, village pharma- reports related to the composition of foods and food cies, and “health huts,” were expanding, applying consumption patterns. However, reports at the time mounting pressure on the Ministry of Health to train suggest that a lack of adequate resources made the growing cadre of community health workers. In the BANAS ineffectual. A change in the name of the simultaneous moves toward decentralization and in- nutrition unit from BANAS to the Service de l’Ali- tegrated services, rural health centers were seen as mentation et de la Nutrition Appliquée du Sénégal “strategic fixed points for integrating and coordinating (Nutrition and Food Service of Senegal) (SANAS) key preventive and curative programs” (World Bank during this period was inconsequential. 1982). The shift in policy “far outstripped the Gov- ®® ITA continued to function primarily as a food technol- ernment’s ability to put in place basic pre-conditions” ogy research center, carrying out the development (World Bank 1982). Evolution of Nutrition Policy in Senegal 17 IMPACT Programs. All told, despite progressive policies, the tion. The program suffered from poor targeting, poor infrastructure for coordination and delivery of nutrition quality care, and food thefts that resulted in the arrest services in Senegal during this period was weak and of community agents and the closing of the project in remained focused primarily on facility-based curative disgrace. Concurrently, Programme Santé Sécheres- care and food supplementation targeted at urban cen- se, implemented by the World Food Programme (WFP) ters.14 This period witnessed Senegal’s first large-scale provided direct response to drought victims. After PPNS nutrition programs, financed and implemented with was finally closed, the Nutritional Rehabilitation and substantial support of international donors (bilaterals, Surveillance Programme to provide food assistance and UN agencies and international NGOs), even though, nutritional rehabilitation and PSMI/PF were instituted. in the global nutrition discourse, questions were being raised about the merits of these types of interventions Meanwhile, in 1982 the World Bank launched the and their prospects for improving nutrition outcomes.15 Rural Health Project, the Bank’s first operation in Key programs implemented during this period—the the health sector in Senegal. Although not strictly a PPNS (1973–88), complemented by Programme nutrition project, it aimed to strengthen Senegal’s in- Santé Sécheresse starting in 1975, and later replaced stitutional and health services delivery capabilities by the Nutritional Rehabilitation and Surveillance Pro- and, in doing so, to restore the credibility of the health gram (1989–95) and the PSMI/PF (1989–95)—were system and capacity to manage outreach programs formally launched by national documents of reference. at the village level. A separate nutrition project—the Integrated Food and Nutrition project—was prepared Though ultimately deemed a failure, PPNS supported but was not approved because of the complexity of its delivery of nutrition services through health posts, in- proposed village-level interventions and the degree of cluding nutritional rehabilitation, distribution of food institution building required (World Bank 1982). Oth- to malnourished children and pregnant and lactating er international partners, including the UN agencies women (PLW), pre- and postnatal consultations, growth (United Nations Development Programme (UNDP), monitoring of children under five, and nutrition educa- FAO, WHO, and UNICEF) and bilateral donors (Bel- 18 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal FIGURE 1:  Stunting of Children Under Five in FIGURE 2:  Wasting of Children Under Five in Senegal, 1992–2014 Senegal, 1992–2014 40 12 35 10 30 8 25 Percent Percent 20 6 15 4 10 2 5 0 0 1992 1993 1996 2000 2005 2011 2012 2013 2014 1992 1993 1996 2000 2005 2011 2012 2013 2014 Source: UNICEF et al. 2016. Source: UNICEF et al. 2016. gium, Canada, the Federal Republic of Germany, opment of public health infrastructure would ultimately France, the Netherlands, and the United Kingdom), be good for nutrition, the nutrition unit itself was se- were also implementing or providing technical support verely underresourced. and training for nutrition-related health, agriculture, and education projects of various sizes.16 In the agri- Institutional Ownership. Despite significant restructur- culture sector, however, many crop development and ing during this period, the institutional home for nutrition diversification schemes were implemented with slight formally remained with the nutrition unit of the Ministry regard for their social or nutritional relevance. of Health, now called SANAS. However, the designation of CANAS as a coordinating body and the sponsorship of key food and nutrition policy by a ministry other than Key Themes the Ministry of Health indicate that, informally at least, ownership of nutrition may have lain elsewhere. Also, By the early 1990s, when the global nutrition community there are indications that commitment to nutrition within was gaining momentum, Senegal already had over 15 the Ministry of Health itself was weak.18 years’ experience in multisectoral nutrition intervention, albeit with limited success and many lessons learned. Multisectoral Coordination and Collaboration. Var- During this period, the nutrition situation sharply deteri- ious nutrition-related activities were carried out during orated. Early mismanagement and poor results set the this period by several ministries. The debate, first stage for the overt politicization of nutrition. documented in the 1960s, around the distinct roles for coordination of nutrition versus delivery of direct Nutrition Championship. Under the presidency of nutrition services seems to have culminated in this pe- Abdou Diouf, nutrition continued to feature prominent- riod in the creation of CANAS, a cross-sectoral body ly in national documents of reference and, formally, responsible for coordination across ministries of nutri- remained high on the political agenda. Political com- tion activities. The actual degree of coordination and mitment was made serious by promulgation of the collaboration among ministries is unknown, but given 1977 Food Investment Strategy for food and nutrition. limited capacity at the community level it seems like- Financial commitment to nutrition, however, did not ly that ground-level coordination and collaboration for keep pace.17 Although public investment in the devel- nutrition activities may also have been quite limited. Evolution of Nutrition Policy in Senegal 19 Community Ownership. Decentralization reforms and relief. The prevailing perception during this period during this period were intended to give more power was that public facilities failed to meet the health needs to local government and increase community owner- of the population. A major shift in public health policy ship of public monies. Creation of the rural community was underway, however, toward integrated services, in- administrative unit created for the first time a platform cluding nutrition. Despite deep design and operational for delivery of services at the village level. Nutrition ser- flaws in nutrition programming, the foundation for inte- vices, to the extent they existed, continued to consist grated services and delivery platforms was laid. of facility-based curative care targeted at urban areas. Nutrition services in rural areas were primarily carried Partner Engagement. Faced with simultaneous envi- out by NGOs, and often with minimal coordination with ronmental and social crises, government dependence stakeholders. Community-based nutrition services on international partner financing and support increased were nascent. Pilot studies carried out by USAID and during this period. Meanwhile, the presence of regionally others during this period evaluating the effectiveness of influential research organizations and the implementa- community-based delivery of growth monitoring, food tion of operational research conducted by donors made distribution, and nutrition education were criticized for Senegal a testing ground for community-based nutrition circumventing the network of public health centers. intervention and secured Senegal’s place as a contribu- tor to the growing global evidence base. Integrated Services and Delivery Platforms. The Sa- helian drought and the emergency that ensued shifted The key nutrition-related policies and influences for the focus from development to humanitarian assistance this generation are listed in box 2. BOX 2: Nutrition-Related Policies and Influences during the Curative Approach Generation 20 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 4 Institutionalization of Nutrition (1990s–2000s) A reorientation toward a preventive approach through integrated intervention packages and community-based interventions in an effort to “do things better” for nutrition Nutrition Context 1991 it was reported that, “no country in sub-Saharan Africa has improved its nutrition status since 1980.” Senegal. As we enter the 1990s, GDP per capita in (Abosede and McGuire 1991, 4). However, early op- Senegal was still in decline, over two-thirds of the erational research in the delivery of community-based population was living below the poverty line, and Sene- nutrition services in the 1980s led, during this period, gal’s economic and social indicators were poor, even in to remarkable progress in the design of preventive comparison to neighboring countries and low-income integrated nutrition interventions such as the Actions countries generally. In 1994, structural adjustment re- Essentielles en Nutrition (Essential Nutrition Actions) forms of the 1980s culminated in a sudden devaluation (AEN) and the Prise en Charge Intégrée des Mala- of the CFA franc, imposed by the IMF. The conse- dies de l’Enfant (Integrated Management of Childhood quence was rapid inflation, deterioration of food and Illness) (PCIME). Also during this period, mounting ev- nutrition security, and urban unrest, particularly among idence provided by Sommer et al. (1986) on the impact young urban professionals. Existing nutrition programs of vitamin A deficiency on mortality motivated global had proven to be unsuccessful, and the government commitment to the delivery of periodic high dose vita- lacked or was unable to allocate adequate resourc- min A supplementation through mass supplementation es to support social programs; the unfolding financial campaigns that began in the mid-1990s with support and social crises shifted national nutrition discourse to from the World Bank, USAID, and Canada. a focus on humanitarian assistance. Riding in on this wave of unprecedented economic and social upheav- AEN is a framework originally developed by USAID, al, President Wade, elected in 2000—Senegal’s first WHO, and UNICEF for managing the advocacy, plan- democratic transfer of power to another political par- ning, and delivery of an integrated package of nutrition ty—would emerge as a strong champion for nutrition. interventions to improve public health (USAID et al. 2011). AEN promotes a “nutrition through the life cy- Global and Regional. Failure to achieve results for nu- cle” approach—comprising seven areas of action: (1) trition during this period were not unique to Senegal. In women’s nutrition; (2) breastfeeding; (3) complementa- Evolution of Nutrition Policy in Senegal 21 ry feeding; (4) nutritional care of sick and malnourished al partners. National documents of reference during children; (5) prevention and control of anemia; (6) vita- this period continued to prioritize nutrition and played min A deficiency; and (7) iodine deficiency—to deliver an important role in guiding nutrition programming. In the right services and messages to the right person at particular, the 1996 9th PODES for the first time ex- the right time using all relevant program platforms. plicitly framed malnutrition as a public health problem, in recognition of its widespread and long-term impact, PCIME is a strategy originally developed by WHO and reoriented intervention toward holistic preventive, and UNICEF to reduce child mortality and morbidity rather than curative, approaches. in developing countries. PCIME addresses the major causes of death in children by improving case man- Lacking any formal, overarching national nutrition agement skills of health workers, strengthening the strategy, however, nutrition policy during this period health care system, and addressing family and com- was in effect defined by whatever nutrition programs munity practices (Partnership for Maternal, Newborn were in place. Institutional ownership of nutrition was and Child Health 2006). PCIME became the main child transferred from the Ministry of Health—the institution- survival strategy in many African countries. al home for nutrition since independence—to AGETIP. Even though AGETIP had no prior experience in health The global community of nutrition partners, the World or nutrition programming, it was chosen as the institu- Bank included, set about advocating for and imple- tional home of the new World Bank-funded Projet de menting community-based and integrated nutrition Nutrition Communautaire (Community Nutrition Proj- projects in Senegal and elsewhere. In 1992, FAO and ect) (PNC). Previous World Bank-supported health WHO convened the International Conference on Nutri- projects19 had been deemed unsatisfactory and, in tion (ICN), the first global conference devoted solely to accord with the experiences of other international nu- nutrition, with representatives of 159 countries and the trition partners working in Senegal at this time, the participation of the UN agencies and over one hundred World Bank considered the Ministry of Health to be NGOs. The year 2000 marked the Millennium Summit cumbersome and ineffective. PNC was designed to and adoption of the MDGs, including the goal to halve, operate in “rapid response” to the crisis; AGETIP was between 1990 and 2015, the proportion of people who determined to be both a more efficient and effective suffer from hunger. By the end of this period, all eyes institution and to have the capacity required to man- turned toward galvanizing action to reach the MDGs. age a project that was ostensibly a nutrition-sensitive social safety net and youth employment operation. Nutrition Policy PNC was the World Bank’s first foray into nutrition pro- gramming in Senegal. During this period, governments, Policies. An historic shift in nutrition policy was including Senegal, were urged by the World Bank to underway in Senegal. This period witnessed institution- create agencies like AGETIP to circumvent the corrup- alization of the first national nutrition-specific policies, tion common to large public works contracts. However, largely echoing global advocacy in preceding years, this shift in responsibility for nutrition—perceived by such as the Interministerial Decree Establishing the some as a “marginalization” (Ndiaye 2010) of the Minis- Conditions for Marketing Breastmilk Substitutes and try of Health—would prove pivotal and would influence ratification of the Baby Friendly Hospital Initiative (both nutrition policy and politics in Senegal for the next 20 in 1994) and, also in 1994, the Salt Iodization Strategy years. In fulfillment of its new mandate—and with the to Fight Iodine Deficiency Disorder (IDD), which cul- confidence of the President—AGETIP made decisions minated in 2000 in a Decree Mandating Universal Salt without the engagement of the Ministry of Health and Iodization. Each of these policy initiatives was led by without regard for existing Ministry policies. The im- the Ministry of Health with the support of internation- portance of this momentous shift in nutrition policy is 22 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal FIGURE 3:  Organogram of PNC “implementation capacity, management structures, or practices to deliver” (Garrett and Natalicchio 2011, National Commission 68), the World Bank management for nutrition in Sen- against Malnutrition egal approached AGETIP. AGETIP AGETIP had a strong track record for good manage- contract manager ment, as well as institutional and absorptive capacity; NGO/GIE NGO/GIE that is, AGETIP had the capacity to execute projects supervisor supervisor and disburse money. AGETIP was receptive to the GIE GIE GIE GIE project as a means of fulfilling its mandate for job cre- service service service service ation through the delivery of nutrition services. It was delivery delivery delivery delivery an innovative, if controversial, approach. the World Community Community Community Community Bank conditioned the project financing on creation of Steering Steering Steering Steering a high-level oversight committee. According to inter- Committee Committee Committee Committee views conducted for this report, the head of AGETIP had connections to then–President Diouf, and an Source: Marek et al. 1999. Note: NGO = nongovernmental organization. GIE = microenterprises. agreement was made to create the CNLM in the Pres- ident’s office with a mandate to ensure the availability further underscored by the development in 1997 of a of a safety net for the poor and responsibility for over- National Plan of Action for Nutrition20 by the Ministry sight of PNC (figure 3). As a result, in 1995, Senegal’s of Health in collaboration with ITA, the Ministry of Ag- first at-scale multisectoral community-based nutrition riculture, and the Ministry of Rural Development. The project was born with almost no engagement of the 1997 National Plan of Action was never executed for Ministry of Health. lack of funds; it is notable, however, for being the first effort in Senegal to develop a national multisectoral A Technical Advisory Committee consisting of “lead- plan for nutrition and indicative, therefore, of important ing professionals from Senegalese universities and progress in the evolution of nutrition policy. medical schools and representatives from interna- tional technical agencies” (Garrett and Natalicchio Institutions. Like other international organizations at 2011, 69) was created to design and support AGETIP. the time, and with mounting evidence as to the im- CNLM itself was composed of representatives from portance of early nutrition on long-term human capital the Prime Minister’s Office, the Ministries of Econo- development, the World Bank nutrition staff were anx- my, Finance, Health (including the nutrition unit, now ious to start a nutrition project in Senegal. Previous called the Service National de l’Alimentation et de investments had been made to expand and improve la Nutrition (National Service of Food and Nutrition) health infrastructure, but there was neither investment (SNAN), Women’s, Children’s and Family Affairs, the specifically for nutrition nor work being done at scale Food Security Commission, AGETIP, and NGOs and at the community level. A nutrition project prepared in civil society organizations. However, lacking any in- 1982 had been deferred for lack of local capacity. The centive structure, budget for supervision, or clear roles 1994 devaluation of the CFA franc and the deteriorat- and responsibilities to maintain the engagement of ing economic and social situation offered a window implementing partners, representatives became “indif- of opportunity for engagement in nutrition. the World ferent” and the CNLM “dysfunctional” (Ndiaye 2007). Bank approached the Ministry of Health to initiate a community-based nutrition project, but the Ministry Regular CNLM meetings occurred but they were purportedly was not interested. Having failed to gain largely formalities. Partner line ministries were not in- traction and skeptical that the Ministry had sufficient volved in project implementation and monitoring and Evolution of Nutrition Policy in Senegal 23 evaluation processes were weak. “Anchorage” of the PNC was also innovative for contracting with young CNLM in the President’s office and “marginalization” people organized in Groupements d’Interet Economique of the Ministry of Health were “perceived as . . . delib- (microenterprises) (GIEs) for the management, training, erate move[s] to keep financial resources outside the delivery, and supervision of preventive nutrition services control of the Ministry . . .” (Ndiaye 2007). In essence, at the community level. The design was based on In- implementation of PNC created a parallel system, and dia’s Tamil Nadu and Tanzania’s Iringa projects, and the shift in institutional ownership of nutrition to AG- other projects that used a contract approach for hos- ETIP sidelined the Ministry of Health’s involvement in pital-based care (Marek et al. 1999). PNC’s nutrition PNC’s design and implementation. In turn, rather than and youth employment objectives met at the community reap benefits for the sitting administration, the Minister level, and, in essence, PNC was a community-based of Public Health, who was from the opposition party, nutrition project created in response to urban unrest. purportedly instituted a Ministry-wide unwritten policy Nutrition services were delivered by the GIE, four previ- of noncooperation with CNLM and PNC. ously unemployed youth from the community—although with only nominal expertise in nutrition—who themselves Programs. Given its catalytic role, PNC (funded by the had been trained by local consultants or institutions and World Bank with support from WFP and the German supervised by a Maître d’Oeuvre Communautaire (proj- Development Bank) is the most historically important ect manager) directly hired by AGETIP. Establishment of nutrition program implemented during this period. De- local steering committees in each PNC community and signed by the Technical Advisory Committee of the district level coordination mechanisms helped to ensure CNLM, it was a large-scale nutrition intervention that efficient execution of project activities. was innovative in several ways, first and foremost for being multisectoral. Given its institutional home in Ultimately, although PNC was a popular project be- AGETIP, PNC was necessarily as much a youth em- cause it delivered nutrition services and much-needed ployment operation as it was a nutrition intervention. employment in urban areas, it suffered from severe The nutrition objective was to prevent the deteriora- challenges of targeting, cost, coordination, quality, tion of nutrition among the most vulnerable (defined as and corruption. Because PNC was intended, in part, malnourished children under three and PLW) in target- to quell urban unrest in the aftermath of the devalu- ed poor urban areas. ation of the CFA franc, it targeted urban areas even though the highest burden of malnutrition was in ru- Through Community Nutrition Centers, PNC activities ral areas. And, because the program relied heavily included growth monitoring of children under three; on food distribution and was run out of community provision of a weekly take-home food supplement for nutrition centers, PNC costs were very high. Despite six months for underweight children; weekly nutrition PNC’s catalytic importance for putting multisectoral and health education sessions for PLW; provision of a cooperation on the national development agenda, weekly take-home food supplement for three months reports indicate that cross-sectoral coordination was for pregnant women during the last trimester of their largely unsuccessful, with line ministries inadequate- first pregnancy and for six months for all lactating wom- ly involved and little effort made to build the capacity en with a child in the program or with an infant younger of state actors. In particular, coordination of referrals than six months; referrals for unvaccinated women from PNC community nutrition centers to the Minis- and children; and provision of communal potable wa- try of Health–supported health centers for identified ter sources (drinking water stand pipes), managed cases of SAM were a key failure. Health centers pur- by local women’s groups. The food supplement was portedly suffered a “lack of expertise in nutrition case locally produced in Senegal. In addition to individual management, inadequate materials, and failure to nutrition counseling, mass media was used to deliver provide needed special nutritional supplements” (Gar- nutrition messaging to the population at large. rett and Natalicchio 2011, 72). 24 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal IMPACT Finally, PNC was not the only nutrition project imple- sis on improving the reach of health programs through mented at this time; duplication of effort and parallel community-based intervention. BASICS piloted a programming are among the many criticisms of PNC. Paquet d’Activités Intégrées de Nutrition (Package During this period SNAN carried out various nutrition of Integrated Nutrition Actions) (PAIN) that combined activities with support from international partners such AEN and PCIME, and was later adopted as a nation- as USAID, UNICEF, WHO, and World Vision. Although al strategy by the Ministry of Health. BASICS also these activities collectively are referred to in histori- conducted important formative research on nutrition cal records as the “National Nutrition Programme” communication to identify best practices of commu- (Ndiaye 2010), it is more accurate to say that it was nity-based nutrition programming, and developed a collection of nutrition activities that remained under information, education and communication (IEC) ma- the Ministry of Health’s control. Chief among these terials, including counseling cards and the use of radio activities were policy-level advocacy initiatives, such for social marketing of behavior change. As cited in as support of the International Code of Marketing of the 2001 LPDN, all of this was carried out through the Breastmilk Substitutes, the Baby-Friendly Hospital Ini- SNAN with no coordination with CNLM or PNC. tiative, and mandated salt iodization and micronutrient supplementation; training of Agents Communautaires (Community Agents); continued support of nutritional Key Themes rehabilitation through the CRENs; and oversight of several important at-scale projects, including the US- This period represents a deepening institutionalization AID/BASICS project, biannual National Micronutrient and politicization of nutrition through a controversial Supplementation Days for vitamin A, and biannual Na- move to anchor nutrition outside the Ministry of Health. tional Vaccination Days, which were (finally) initiated There were also some important firsts, including the with support from the Micronutrient Initiative (MI) and first nutrition-specific legislation, an attempt at an UNICEF.21 overarching multisectoral national plan (which was never implemented), and the first large-scale com- From 1994–2006, BASICS was USAID’s multipartner munity-based nutrition project. PNC is, however, best child survival project that supported the Ministry of understood as a rapid response operation: Nutrition Health in scaling up implementation of evidence-based interventions were still primarily oriented toward iden- interventions proven to be effective in preventing and tification and rehabilitation of malnourished children; treating the major causes of newborn and childhood most PNC funding was spent on food supplementa- death, including malaria, pneumonia, diarrhea, mal- tion and provision of drinking water; and the overriding nutrition, birth complications, and HIV/AIDS. BASICS objective was to quell urban unrest through youth em- was operational in over 20 countries and worked in 22 ployment. Although ultimately deemed a failure, PNC of Senegal’s 56 health districts, placing strong empha- provided valuable lessons and led to mobilization Evolution of Nutrition Policy in Senegal 25 around the importance of multisectoral collaboration contracted GIEs to the communities they served was that would later inform the design of the PRN. leveraged to increase coverage of nutrition services while employing locally appropriate approaches and Nutrition Championship. This was a period of crisis, intervention strategies. By and large, this would form and any momentum for nutrition built in previous gen- “the foundation of the operational scheme and success erations was subsumed by the emergency response. of PRN” (Ndiaye 2010, 11). In addition, the USAID/BA- Important progress was made, however, when the SICS project supported the Ministry of Health’s efforts responsibility for nutrition was rescued from oblivion to capitalize on and implement global innovations in in the Ministry of Health and placed in a position of community-based delivery of nutrition services. relative prominence in the President’s office under the competent management of AGETIP. Integrated Services and Delivery Platforms. This was the generation that launched large-scale im- Institutional Ownership. The monumental shift in plementation of preventive integrated services and anchorage that established institutional ownership of delivery platforms. With support from USAID, the nutrition outside the Ministry of Health set an important Ministry of Health adopted PAIN as the strategy for precedent. However, the specific institutional arrange- nutrition service delivery. Efforts were underway ments and the political tensions that resulted from to build capacity to deliver nutrition services at the the move created “a weak basis for sustained action” community level and to link these community-based (Garrett and Natalicchio 2011, 71). interventions to the health system. Although PNC im- plemented an innovative approach to engaging local Multisectoral Coordination and Collaboration. organizations and communities in community-based Substantive, if partial, progress was also made in nutrition service delivery, the failure of PNC and the cross-sectoral collaboration for nutrition. First was the Ministry of Health to coordinate (there was no link development of the National Plan of Action for Nutrition, whatsoever) meant that health facilities were ill-pre- a multisectoral national nutrition plan, spearheaded by pared to receive and follow up on referrals from the the Ministry of Health in partnership with ITA, and the community. Most health facilities were too poorly ministries of Agriculture and Rural Development. Al- staffed and too poorly equipped to manage the re- though the National Plan of Action for Nutrition was ferrals received. Moreover, with BASICS operational never implemented, it marked an important advance. in fewer than half of Senegal’s districts and PNC op- Second was creation of the CNLM, which also marked erating only in urban areas, nutrition service delivery an important development in Senegal’s path to institu- was not yet at scale. tionalizing multisectoral cooperation for nutrition. That this effort at coordination failed because of insufficient Partner Engagement. This period marks a significant incentives and mechanisms for engagement of other increase in the number of international partners work- ministries provided valuable lessons for the future. ing on nutrition in Senegal, and the first World Bank nutrition investment. Also, for the first time, private or- Community Ownership. Important and innovative ac- ganizations were contracted by government to deliver complishments increased community engagement and preventive nutrition services. demonstrated that decentralized preventive services contracted through local NGOs could have an impact The key nutrition-related policies and influences for on nutrition outcomes. Through PNC, the proximity of this generation are listed in box 3. 26 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal BOX 3: Nutrition-Related Policies and Influences during the Institutionalization of Nutrition Generation Evolution of Nutrition Policy in Senegal 27 Photo: Adama Cissé/CLM 5 Intensification and Decentralization (2000s–2010s) A decade of action for nutrition that turned the tide for nutrition policy in Senegal with rapid improvement in nutrition outcomes Nutrition Context stunting prevalence in Senegal was lower than the av- erage for Sub-Saharan Africa. Prevalence of wasting Senegal. The election of Abdoulaye Wade in March and underweight held steady at about 10 percent and 2000 changed the political scene in Senegal dramat- 20 percent, respectively. With persistent high rates ically. After 40 years of leadership by the Socialist of stunting, a scandal-ridden and fractured system of Party, Wade was Senegal’s first president from the nutrition service delivery, and a newly elected adminis- Senegalese Democratic Party. Whereas the Socialist tration with a mandate for change, it was an uncertain Party espoused state control, the Wade administration time for the future of nutrition policy. However, in this promoted a more progressive approach to economic period nutrition was understood to be a critical com- development characterized by a more pluralistic envi- ponent of human development, and President and ronment, promotion of the private sector and—in stark First Lady Wade were visible nutrition champions. contrast to the economic reforms of the previous gener- The decade of the Wade administration—from 2000 ation—greater emphasis on the development of human to 2012—marked a period of unprecedented intensifi- capital through improvements in healthcare, education, cation of action to reduce malnutrition in Senegal that and employment. Despite earlier efforts to expand the produced unprecedented results. reach of social services, access remained limited, qual- ity was poor, and there were marked inequities across During this period, efforts to decentralize social ser- regions and between urban and rural areas. At this vices were redoubled, and policy change—formal, time, approximately 80 percent of the urban population institutional, and programmatic—finally turned the tide lived within 30 minutes of a health facility, compared to for nutrition in Senegal. Revision of the national consti- only 42 percent of the rural population. tution in 2001 included codification of the right to food. Another important milestone for Senegal was partici- In 2000, the prevalence of stunting remained high at pation in the first Countdown to 2015 event in London 29.5 percent, although there was a small but marked in 2005. In the lead-up to the event, then–Prime Min- decrease compared to a decade prior (figure 1), and ister, and current President, Macky Sall coauthored Evolution of Nutrition Policy in Senegal 29 with the Prime Minister of Madagascar a letter to the This period is also notable for the 2007–08 global food editor of The Lancet, entitled “African Prime Ministers price crisis which, while not having a major impact on Take Lead in Child Survival” (Sall and Sylla 2005), in Senegal, helped to reinvigorate donor commitment to response to the journal’s admonishment that “global nutrition and support the rollout of CMAM. As the Paris child-survival efforts now need to broaden to include Declaration22 committed donors to support govern- not just international organisations but also ministers ment ownership, the push for scale-up in financing for of health, prime ministers, and presidents in the most nutrition took place against the backdrop of donor con- affected countries” (Lancet 2005). cern that increasing foreign assistance might weaken government commitment to reforms. Global and Regional. Globally, this period was marked by increasing momentum for nutrition in the MDGs, fed by landmarks such as work by David Pel- Nutrition Policy letier et al. (1994) demonstrating that approximately half of child mortality was attributable to malnutrition; Policies. With the inauguration of the Wade admin- the Copenhagen Consensus in 2004, which concluded istration came a flurry of new policies and initiatives that nutrition was among the top development invest- having far-reaching implications for nutrition. In 2000, ments; publications such as the Global Strategy for Senegal, with support from the World Bank, developed Infant and Young Child Feeding (WHO and UNICEF its first Document de Stratégie de Réduction de la 2003), which advocated and provided a framework for Pauvreté (Poverty Reduction Strategy Paper) (DSRP) action to improve nutrition and child survival through based on four pillars: wealth creation through econom- optimal feeding; the WHO Child Growth Standards: ic reform and private sector development; capacity Methods and development (WHO 2006), which pro- building and development of social services; improve- vided a new international benchmark for assessing ments in the living conditions of vulnerable groups; the nutrition status of children; Repositioning Nutri- and implementation of the strategy and monitoring of tion as Central to Development in 2006 (World Bank its outcomes. Importantly with regard to nutrition poli- 2006), which offered a global development strategy; cy, both the first DSRP in 2000 and the second DSRP the Lancet Series on Maternal and Child Undernu- in 2006 codified what had been learned through the trition (2008), which catalogued the evidence for the preceding five years of nutrition programming with causes and consequences of malnutrition, identified a PNC—it articulated the importance of a coherent mul- package of proven interventions, and called for global tisectoral approach to addressing malnutrition and action to improve nutrition for mothers and children; provided the institutional and financial means for it. and the emergence of the SUN Movement in 2010. In essence, President Wade doubled down on the insti- Another important influence on global nutrition dis- tutional approach to nutrition introduced by PNC, albeit course and a huge advancement in nutrition service with major modifications. Widespread criticism of PNC, delivery was the innovation of Community Management especially with regard to the marginalization of key of Acute Malnutrition (CMAM), first piloted by Valid In- ministries and the overall failure of efforts at multisec- ternational in Ethiopia and Malawi. CMAM’s use of toral coordination, accusations of corruption, and little Ready to Use Therapeutic Food was nothing short of a evidence of impact on nutrition, fueled calls for restruc- revolution in the treatment of SAM, for which previous turing. In 2001, an executive decree created a new treatments had been considered by the World Bank entity, the CLM to replace the CNLM; the institutional and other international nutrition partners to be ineffi- home for nutrition was moved to the Prime Minister’s cient and ineffective. The 2008 Lancet Series included office. The BEN was created as part of the CLM to CMAM among the cost-effective nutrition interventions, be the permanent executive office in charge of day- paving the way for global advocacy and support. to-day management. The BEN was then identified as 30 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal FIGURE 4:  Organogram of PRN eight strategic principles for action: equity, decentral- ization, partnership, contractualization (outsourcing President of services), community ownership, transparency, Unit for the Fight against Malnutrition (CLM) sustainability, and ethics. The 2001 LPDN nutrition strategy encompassed the following nine components, Sector ministries Local communities each with clearly delineated priority actions: Private Decentralized Community sector services agencies ®® Strengthening of the community approach with PAIN and the Prise en Charge Intégrée de la Mala- Source: Ka 2011. die l’Enfant au Niveau Communautaire (Community Integrated Management of Childhood Illnesses) the implementing agency responsible for executing the (PCIME-C); new World Bank-funded nutrition project, PRN (figure ®® Strengthening food security by improving agricul- 4). At this time, nutrition was also added as a distinct tural production, food research, and distribution of investment line in the national budget.23 Though the food; investment line was time-bound (as opposed to an op- ®® Improving the supply of potable water and sanitary erational line, which covers overhead costs and is more living conditions; permanent), it was a major step toward ensuring insti- ®® Reorganization and strengthening of institution- tutionalization and sustainability of funding for nutrition al frameworks for piloting and managing nutrition beyond the life of any single project or administration. projects; ®® Strengthening partnerships with local collectives, CLM was charged with articulating a “new vision” for NGOs, associations, Agences d’Exécution Commu- nutrition intervention in Senegal. Among its first re- nautaire (Community Executing Agencies) (AECs), sponsibilities was writing the LPDN to define—for the and the private sector in the implementation of pro- first time—national nutrition policy and elaborate ap- grams to fight malnutrition; propriate strategies for programming and monitoring. ®® Improving systems for collecting, analyzing, and Although underlying party politics likely played a role, disseminating data on food, nutrition, and promo- the World Bank conditioned receipt of PRN financ- tion of studies and research; ing on these institutional arrangements in an effort to ®® Strengthening the capacity of human resources at establish a long-term, national, community-based pro- the community level; gram for nutrition (rather than a project), anchored in ®® Strengthening IEC and BCC programs; and a policy and institutional framework with high political ®® Development of income-generating activities visibility to secure the enabling environment required for effective multisectoral cooperation. That is, the In the lead-up to PRN, the World Bank management for LPDN was a prerequisite for the World Bank financing; nutrition in Senegal had changed. A bold and innovative as a result, through PRN nutrition intervention in Sen- approach to the preparation of PRN was undertaken egal evolved from a “project approach” to a “program that would prove to be instrumental to the long-term approach” (Ndiaye 2007). success of the program. PRN was designed through a series of participatory workshops that included rep- The LPDN called for urgent attacks—both direct resentatives from all nutrition-related ministries, the and indirect—on the multiple causes of malnutrition Ministry of Finance, donors, and NGOs. The purpose and food and nutrition insecurity across all sectors, of the participatory process went beyond simply project in particular by the Ministries of Health, Education, preparation. The workshops enabled the participants Agriculture and Livestock, Fisheries, Family and Na- to bring to light and debate emerging global evidence tional Solidarity, Early Childhood, and Trade. It defined for the causes and consequences of malnutrition and Evolution of Nutrition Policy in Senegal 31 appropriate strategies for intervention in Senegal. Hav- points for coordination. At the lowest level, the com- ing all stakeholders at the table—many of whom were mune, the AEC was in charge of the community-based not nutrition experts—enabled an authentic dialogue nutrition projects with higher administrative levels and a transparent decision-making process. (such as the sous-Préfecture, Préfecture and Regional Governor) involved in program monitoring and coor- Instrumental to the effectiveness of these discussions dination across sectors. PRN was further specified in was the strategic use of the USAID-funded PROFILES Strategic Plans for each phase of the program. policy development and advocacy tool, which estimated the economic and social benefits, as well as the pro- In 2006, the LPDN was revised to account for the gram costs, of nutrition intervention in Senegal, enabling evolving global, regional, and national contexts, such decision makers to “see for themselves the return on in- as the emergence of the MDGs, the Global Strategy vestment in nutrition” (Garrett and Natalicchio 2011). In for Infant and Young Child Feeding, the New Partner- short, the evidence laid bare what many already knew, ship for Africa’s Development (NEPAD), and the 10th that is, the need for action in multiple sectors in order PODES, which defined the vision for Senegal as “a to improve nutrition in Senegal. What also was evident country where every individual has a satisfactory nu- was the need to pivot “away from food distribution to tritional status and takes appropriate behavior for their a stronger focus on prevention, behavior change, and welfare and development of the community” (Répub- education” (Garrett and Natalicchio 2011) and to target lique de Sénégal 2006). The 2006 LPDN also reflected rural areas where the burden of malnutrition was higher. the evolving nutrition situation, which was shown by Lessons learned from PNC also provided clues to key new data to include widespread food insecurity and challenges that would need to be addressed, such as disparities in access to nutritious food, as well as implementation capacity, coordination, and community significantly reduced rates of undernutrition and im- engagement. Even well thought out design decisions proved nutrition practices. National nutrition policy would invoke resistance from entities with long-stand- objectives were framed in terms of the MDGs, and the ing financial and political interests in existing systems, guiding principles were reduced from eight to four: eq- such as those for food distribution. However, the work- uity, ethics, transparency, and contractualization. The shops were successful at building consensus and buy-in revised strategies included prioritization of communi- among key decision makers; shared understanding ty-based delivery of efficacious nutrition interventions; among the participants from varied backgrounds and strengthening of food security; strengthening of the experiences; and the trust and commitment required to institutional and organizational capacity of CLM and pave the way for effective collaboration. community-level partners; and improving nutrition in- formation systems. Finally, the 2006 LPDN reflected Among the lessons drawn from the PNC was the im- renewed commitment to the institutional arrangements portance of having an effective platform for ongoing put in place in 2000. Senegal was headed in the right multisectoral collaboration. It was crucial that part- direction, but there was still a lot of work to do. ners remain engaged with the program well beyond the design stage. At the central level, the CLM and Among the strategies included in the 2006 LPDN BEN entered into collaborative agreements with the was improvement of the legislative and regulato- various ministries. Of note, the Ministry of Health was ry framework for food and nutrition. The evolution of the delegated entity responsible for nutrition policy the nutrition political climate is evident in significant within the CLM. Also, money was unabashedly used efforts during this period to strengthen the normative as a “lubricant for intersectoral collaboration” (Garrett framework for nutrition, and the capacity of the Min- and Natalicchio 2011)—PRN funded incentives such istry of Health to implement nutrition interventions. as training, equipment, and technical support for par- Initiatives led by the nutrition unit of the Ministry (now ticipating ministries. Local governments were the focal called Division de l’Alimentation de la Nutrition et de 32 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal la Survie de l’Enfant (Division of Food, Nutrition and oversight of national nutrition studies. With responsi- Child Survival) (DANSE)) with technical and finan- bility for the facilitation and management of resources, cial support of external partners—such as the 2001 CLM is also the primary forum for strengthening co- Nutrition Standards and Protocols, which established operation among partners and determining concrete criteria for service quality; the PCIME Strategic Plan actions that enhance collaboration for nutrition. 2002–2007; the Politique National pour l’Alimentation du Nourrisson et du Jeune Enfant (National Policy for Finally, the CLM is also responsible, through the BEN, Infant and Young Child Feeding) in 2006; and the Plan for managing the implementation of PRN. The CLM National de Survie de l’Enfant (Strategic Plan for Child does not have its own personnel; rather, direct imple- Survival) (PNSE) in 2007—over time came to be de- mentation is done through local government, NGOs, veloped in coordination with CLM. In 2009, the Plan and public service providers. However, the CLM raises National Développement Sanitaire et Social (National and allocates money, and through three Bureaux Ex- Health Development Plan) (PNDS), for 2009–18, com- écutif Regional (Regional Executive Offices) (BERs) mitted to the protection of women and children through monitors implementation.24 The BEN is the adminis- delivery of a community-based intervention package trative and technical arm of the CLM, composed of (such as PCIME) that included promotion of exclusive a subset of CLM members. The CLM convenes pe- breastfeeding as a priority action. riodically while the BEN provides day-to-day support, including disbursement of CLM budget. The head of Also during this period, years of work by key part- the BEN is the National Coordinator for Nutrition. As ners such as Helen Keller International (HKI), MI, and PRN is a program of the CLM managed through the UNICEF culminated in 2009 with two landmark nutrition BEN, the National Coordinator for Nutrition is also the policies: the Decree Mandating Vitamin A Fortification coordinator of PRN. CLM’s dual role in the coordina- of Oil and the Decree Mandating the Fortification of tion and implementation of nutrition policy has been Wheat with Iron and Folic Acid. Policy developments viewed as one of the key factors for its success. in other sectors also contributed to the improvement of nutrition service delivery. The Plan de Développement Several other institutions played a key role in the evolu- Communal (Communal Development Plan) (PDC) and tion of nutrition policy in Senegal during this period. The the Programme Nationale de Développement Local Comité Sénégalais pour la Fortification des Aliments (National Program for Local Development) (PNDL) in en Micronutriments (Committee for Food Fortification) 2002 aimed to strengthen the capacity of local govern- (COSFAM), formed in 2006, is a subcommittee of CLM ment to supply social services to the population. focused on reduction of the prevalence of micronutrient deficiencies (such as iron, vitamin A, and iodine) among Institutions. The institutional arrangements estab- women of reproductive age and children under five. lished in the 2000 DSRP and reinforced by the 2006 With the support of Global Alliance for Improved Nutri- revision of the LPDN remain in place as of 2016. CLM tion (GAIN), MI, and other public and private partners, is charged with defining national nutrition policies and the committee was instrumental in the passage of the strategies; planning, coordinating, and overseeing im- decrees mandating oil and wheat fortification in 2009. plementation of nutrition projects and programs; and Likewise, the Comité Technique pour l’Iodation Univer- monitoring results. It is chaired by the chief of staff of selle du Sel (Technical Committee for USI (Universal the Prime Minister’s office with participation from elev- Salt Iodization)) (CTIUS), was formed in 2006, con- en ministries and representatives of NGOs and the sisting of representatives from the Ministries of Health, Mayors’ Association. CLM is the primary reference and Trade, Industry and Cottage Industry, the private sector, monitoring body for nutrition policy, and Senegal’s SUN local governments, and NGOs to support adequate salt Focal Point. It provides technical nutrition advice, sup- iodization among small-scale producers and compli- ports the design of technical reference guides, and has ance with the 2000 mandate for universal salt iodization. Evolution of Nutrition Policy in Senegal 33 The Conseil National sur la Sécurité Alimentaire (Na- ed to do community mobilization for nutrition actions on tional Food Security Council) (CNSA), formed in 1998, behalf of local governments, in collaboration with public sits in the office of the Prime Minister; it predates and service providers and communities, through communi- is a member of the CLM. It was originally established ty steering committees and Agents Communautaires. for the purpose of regularly evaluating the food supply These contracted NGOs constituted the AEC. and nutritional situation. In 2006 it instituted a food se- curity early warning system and is involved primarily Specifically, Agents Communautaires deliver nutrition in decisions concerning food distribution. Given the social behavior change communication (SBCC) through overlapping mandates, coordination between CLM periodic meetings with women’s groups and other non- and CNSA is important. technical sensitization and mobilization activities. They also screen (on a quarterly basis), manage, and refer Programs. The overall objective of PRN was to sup- SAM cases to health facilities as required by shared port the LPDN and contribute to reaching the first MDG protocols, and ensure follow up at the community level. of eradicating extreme poverty and hunger in Senegal. Genuine community engagement and the involvement PRN was conceptualized and funded in three phases: of local NGOs in the delivery of nutrition services and first, the development of strategies and demonstrat- monitoring of results infused a real sense of local own- ing results;25 second, scaling to the national level and ership and responsibility and better supported capacity between sectors;26 and third, consolidating achieve- development of public systems. Originally it was antici- ments. The original 10-year horizon (2002–12)27 pated that government health staff would be responsible provided a structure for gradual scale-up irrespective for supportive supervision of the Agents Communau- of political administration, and the phased approach taires, but this arrangement was untenable. Instead, imposed a “sense of urgency for action” (Garrett and training and supportive supervision of Agents Commu- Natalicchio 2011). Initial funding for PRN was from nautaires was provided by the contracted NGOs. the World Bank. Since 2011, the government has in- creased its ownership, with support from other donors, Simply coordinating nutrition services at the communi- such as UNICEF, the Spanish Cooperation, the African ty level (delivered through NGOs and volunteers) and Development Bank, and the European Union. PRN facility-based nutrition services (Ministry of Health–led was not the only instrument for achieving LPDN goals, and delivered by health staff)—with all partners op- however. With direct oversight from CLM and the BEN erating under the same protocol—was a significant and as the government’s flagship nutrition project, undertaking. Both the 2001 and 2006 LPDNs explic- PRN spearheaded changes in delivery and monitoring itly promoted specific nutrition strategies, including of nutrition services throughout the system. PCIME, the Global Strategy for Infant and Young Child Feeding, and the integrated approach to addressing PRN operates through multilevel and multisectoral micronutrient deficiencies. These constituted the oper- collaboration across participating ministries, NGOs, ational framework developed by the Ministry of Health, the private sector, local government, and the com- with the support of external partners, such as USAID, munity. Among the many lessons applied from PNC in the mid-1990s. The PCIME model consists of three was the importance of leveraging existing structures components: (1) integrated management of ill chil- and programs. The PRN took a different approach to dren in facilities and health centers; (2) health system contractualization, which was first introduced by PNC. strengthening, particularly access to drugs and logistics Given the variation in characteristics and capacities support; and (3) promotion of key family and commu- across regions, it was crucial to empower local NGOs nity practices. It prioritizes prevention, but incorporates to develop their own locally relevant strategies for en- both preventive and curative interventions.28 In partic- gaging the community. Local NGOs, selected through ular, PCIME aims to address gaps in knowledge, skill, a competitive and transparent process, were contract- and community practices regarding children’s health, 34 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal recognition of illness, home management of the sick detected through regular monitoring. In this way PRN child, and appropriate care-seeking behavior. facilitated local capacity building through “learning by doing,” providing “the bare minimum of instructions Small pilots of the full PCIME approach had been im- but maximum support” (World Bank 2007, 13). NGOs plemented in Senegal, but never at scale. The lack also benefited from the visibility gained by being asso- of integration in nutrition service delivery created ciated with a national program, and all partners were huge inefficiencies and missed opportunities, as evi- encouraged to “take credit for results, thus enhancing denced in PNC. PCIME-C—the third component of the ownership and incentives for participation” (Garrett model—was innovative for approaching child growth and Natalicchio 2011, 92). holistically by integrating interventions. PCIME-C prin- ciples and strategies were used in PRN in an effort to By 2011, CLM was responsible for implementing four build on existing structures and programs; link com- other major programs in addition to PRN30: (1) the Pro- munity-based nutrition services with facility-based gramme Iodation Universelle du Sel (Universal Salt nutrition services; and signal a spirit of cooperation Iodization) (PIUS) project with support from the Minis- between PRN and the Ministry of Health. Use of the tries of Health, Commerce, and Industry, and partners PCIME model services underscores that PRN could such as MI, WFP, and UNICEF; (2) the Nutrition En- not achieve its objectives by functioning as an isolat- fant et Sécurité Alimentaire (Child Food and Nutrition ed project; PCIME was “a strategic way to work more Security) (NESA) project with support from the MDG closely with the health service delivery system to pro- Fund through WHO, FAO, WFP and UNICEF; (3) the mote measures that help prevent malnutrition” (Garrett Nutrition Ciblée sur l’Enfant et les Transferts Sociaux and Natalicchio 2011, 93). (Child Targeted Nutrition and Social Transfers) (NETS) project with support from the World Bank; and (4) the Community ownership and results-based manage- Programme de Renforcement de la Fortification (Pro- ment went hand in hand. With PRN, nutrition services gram for the Enhancement of Fortification) (PRF), also expanded to rural areas where the burden of stunt- through the Ministries of Commerce and Industry and ing was highest. Unlike PNC, PRN’s primary objective supported by GAIN and HKI—a “harmonious conver- was to improve nutrition outcomes. Specific nutrition gence of different interventions towards a single goal” outcome indicators were established against which (Ka 2011), to improve the health of children under five progress was measured, including nutrition practices, and PLW. Descriptions of the programs follow: coverage of nutrition services, and nutrition knowl- edge.29 Simple monitoring and evaluation tools were ®® PIUS (2009–15) involved local governments in facil- used to track, on a monthly basis, results at communi- itating adequate salt iodization among small-scale ty, regional, and national levels and inform supportive producers. The project had regional implica- supervision. Sharing of results against expectations tions—80 percent of the salt produced by Senegal and problem solving at the community level were other is exported to other West African countries. mechanisms of community engagement. ®® NESA (2009–12) focused on the prevention and management of malnutrition and reduction of ex- In this way, the PRN “monitoring and learning system treme poverty in response to the 2006–07 drought, involved every partner and stakeholder in measuring and promoted improvement of food security and and discussing results” (Garrett and Natalicchio 2011, nutrition in highly vulnerable areas. 91). Results-based management “contributed to the ®® NETS (2009–11) was one of the first nutrition-sen- quality and results focus of the services provided” sitive social protection interventions to use cash (World Bank 2007, 11) across the entire system. Par- transfers as a rapid response to mitigate the neg- ticipating NGOs received not only extensive training ative impact of the food price crisis on vulnerable but also technical assistance when problems were populations (mothers and children under five). Evolution of Nutrition Policy in Senegal 35 IMPACT ®® PRF (2006–11) supported the 2009 Decrees Man- implemented by USAID, which promotes agricultural dating Vitamin A Fortification of Oil and Fortification development (such as the raising of small ruminants, of Wheat with Iron and Folic Acid by assisting indus- homestead gardening, and aquaculture) for food di- try partners to upgrade and adapt their production versification and to improve child survival and nutrition chain, conduct monitoring and evaluation to ensure at the community level. quality processing, and carry out communication and social marketing. Key Themes Other nutrition-sensitive projects were also being car- ried out during this period in coordination with CLM, The decade of the Wade administration represents a including: (1) the Programme Décennal de l’Edu- peak in both political will and progress for improved cation et de la Formation (Ten-Year Education and nutrition outcomes. In this period, all six key themes Training Program) (PDEF) (2001–11) through the coalesce. The launch of PRN coincided with landmark Ministry of Education with support from PRN and policy development and a major restructuring of in- WFP, a school nutrition project that included deworm- stitutional responsibility for delivery and oversight of ing, iron supplementation, canteens, and hygiene nutrition services. Through a highly inclusive approach and nutrition education; (2) the Programme National facilitated by CLM and BEN, PRN spearheaded d’Investissement Agricole (National Agriculture Invest- systematic change that improved the coherence, ef- ment Program) (PNIA) (2009–20), which established ficiency, and effectiveness of nutrition policy across Community Agricultural Areas and farms incorporating all channels of service delivery. By 2011, Senegal breeding, aviculture, and aquaculture in support of was hailed as a global success story in the progress food security; and (3) the Yaajeende project (2010–17) against malnutrition. Leadership astutely leveraged 36 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal the “visibility of success” to secure additional financing services in Senegal that never reached beyond a small (Garrett and Natalicchio 2011, 94). scale. Its operational flaws notwithstanding, PNC’s in- novative use of contractualization added an important Nutrition Championship. From the start of the Wade facet to effective and sustainable community-based administration, nutrition was taken on as the cause service delivery. The concept of contractualization célèbre for the President and First Lady. Use of re- was repurposed—this time around the PCIME frame- sults-based management meant that early successes work—to great effect for PRN. Rather than working in could be—and were—heralded to promote increased in- isolation, local NGOs were contracted by and on behalf vestment among donors and redouble the commitment of local governments to deliver the community com- of implementation partners. The spirit of shared success ponent of PCIME in collaboration with public service created a cadre of nutrition champions at all levels. providers and communities. In so doing, PRN built upon existing structures and, through PCIME, linked commu- Institutional Ownership. With PRN came another nity-based nutrition services with facility-based nutrition major shift in the institutional anchorage of nutrition, services. Results-based management also enabled but this time with adequate resources and mecha- NGOs to determine for themselves the most effective nisms to foster effective and sustained collaboration strategies for engaging their communities while still pro- across levels and sectors. Among the first duties of viding a means of ensuring that results were achieved. the newly instituted CLM, was the development—after Monitoring of results at the community level was itself a forty years of nutrition intervention—of Senegal’s first means of garnering community ownership. national nutrition policy, based on equity, ethics, trans- parency, and contractualization. Over time—and with Integrated Services and Delivery Platforms. The demonstration of good will and good results—many of launch of the first national nutrition policy in Senegal the political fissures that crippled PNC were overcome. instituted a momentous shift from a “project approach” to a “program approach” and, through cooperation be- Multisectoral Coordination and Collaboration. The tween PRN and the Ministry of Health using the PCIME political environment for nutrition at the close of PNC framework, from a fractured patchwork of services to- was polarized—marked by active resistance from a few ward a more integrated delivery platform (Ndiaye 2007). key actors and total disengagement from most others. Combined, these two achievements marked “a signifi- By contrast, PRN was launched with a spirit of inclusive- cant reorientation in institutional thinking,” fostered ness and cooperation. With all stakeholders engaged collaboration across levels and sectors, and promoted in the preparation of PRN, there was “a greater sense long-term planning (Garrett and Natalicchio 2011, 76). of ownership from the outset” (Garrett and Natalicchio 2011). And although the CLM was initially “plagued by Partner Engagement. In addition to national and local high turnover of representatives from key ministries” government entities, external technical and advocacy (World Bank 2007, 12) (despite operational and financial partners played a critical role in the design of PRN, incentives), as the project produced results, participation as well as in the development of key nutrition legis- and ownership increased. As all partners were engaged lation during this period. Moreover, the decentralized in the delivery of PRN, all partners were invited to share approach to implementing PRN required the engage- in its success. Over time, this “coordination and success” ment of more partners. The national nutrition policy became synergistic, as ministries began to “lobby for provided a framework and the CLM provided the fo- their own budgets to support their own nutrition activi- rum to better coordinate efforts to maximize impact on ties” (Garrett and Natalicchio 2011, 95). nutrition outcomes. Community Ownership. By the year 2000, there had The key nutrition-related policies and influences for been many attempts to pilot community-based nutrition this generation are listed in box 4. Evolution of Nutrition Policy in Senegal 37 BOX 4: Nutrition-Related Policies and Influences during the Intensification and Decentralization Generation Policies Key National Influences • DSRP (2000) • PROFILES Senegal (2002) • Decree Mandating USI (2000) • DHS (2001) (2005) • Revised national constitution (2001) • Flooding (2009) • LPDN (2001) • Senegal Ministry of Economy & Financing Alpha • Executive Decree 2001–770 and Executive Order Award to PRN (2010) creating the CLM and BEN (2001) • Nutrition Standards and Protocols (2001) Key Regional and Global Influences • PCIME Strategic Plan (2002–07) • NEPAD (2001) • 10th PODES (2002–07) • CMAM (2001) (2005) • PNDL (2002) • World Food Summit (2002) • LPDN (revised) (2006) • A World Fit for Children (2002) • National Policy for Infant and Young Child Feeding • Global Strategy for Infant and Young Child (2006) Feeding (2003) • 11th DSRP (2007) • Maputo Declaration on Agriculture and Food • PNSE (2007) Security (2003) • PRN Strategic Plan (2007) • Copenhagen Consensus (2004) • PNDS (2009) • Global Strategy on Diet, Physical Activity and Health (2004) • Decree Mandating Vitamin A Fortification of Oil (2009) • Countdown to 2015 event in London (2005) • Decree Mandating the Fortification of Wheat with • Paris Declaration and Accra Agenda for Action Iron and Folic Acid (2009) (2005) • WHO Child Growth Standards: Methods and development (2006) Institutions • Repositioning Nutrition as Central to Development • CLM, BEN, and BER (2001) (2006) • AEC (2001) • Global Food Price Crisis (2007–08) • Nutrition line item added to national budget (2001) • Lancet Series on Maternal and Child followed by a 10-fold increase (2007) Undernutrition (2008) • DANSE replaces SNAN (2003) • SUN Movement & Scaling Up Nutrition: A • COSFAM (2006) Framework for Action (2010) • CTIUS (2006) • WHA Resolution WHA63.23 on Infant and Young Child Nutrition (2010) Programs • PDEF (2001) • PRN Phase I (2002–05) • PCIME-C (2002) • Essential Nutrition Services Integrated Package for People Living with HIV (2005) • PRN Phase II (2007) • NETS (2009) • NESA (2009) • PNIA (2010) • National Child Survival Program (2010) • Salt iodization project (2010) • USAID/Yaajeende (2010) 38 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 6 Multisectoral Approach (2010s) Senegal assumes its position as a global leader in nutrition intervention; meanwhile efforts are underway to define the future for nutrition policy in a Sall administration determined to achieve emerging country status by 2035 Nutrition Context er, and progress against stunting during this same period appears to have been sustained. During the period of Senegal. In 2012, Macky Sall was elected President the MDGs, stunting decreased a remarkable 44 percent, of Senegal, taking over after two terms of the Wade from 34.4 percent in 1992 to 19.4 percent in 2014. This administration. Economic growth and poverty reduc- singular achievement has solidified Senegal’s place as a tion had already begun to slow. Almost immediately he global leader in nutrition policy. was faced with a natural disaster—flooding following torrential rains—that nearly crippled the new adminis- In 2011, Senegal was invited to present the Interna- tration.31 The severe flooding of 2012 was followed by tional Food Policy Research Institute (IFPRI) 21st poor rainfall in 2014. The end of 2015 marked the end Annual Martin J. Forman Memorial Lecture, in honor of the MDGs; final scorecards are not yet available but of its success “in developing a multisectoral strategy it appears that Senegal had mixed results. Reduction to achieve sustainable nutrition outcomes” (Ka 2011). in extreme poverty (MDG 1a) and gender equality in In the same year, Senegal signed on as a SUN Move- schooling (MDG 3) were achieved. Substantial prog- ment country, signaling its commitment and further ress against child mortality (MDG 4) and toward access raising the visibility of Senegal’s position as a leader to safe drinking water (MDG 7) was made, but likely in nutrition intervention. In his previous post as Prime not enough to reach the goals. Progress on universal Minister—the institutional home for CLM and BEN— primary education (MDG 2), maternal mortality (MDG Macky Sall had a close perspective on the evolution 5), and HIV/AIDS (MDG 6) was clearly insufficient. of the nutrition policy that unfolded over the previous decade. The role that nutrition will play in the Sall ad- After having achieved significant progress against hunger ministration is as yet undetermined, but the foundation (MDG 1c) from 1990 to 2010, the prevalence of under- from which to redouble efforts to make progress for nourishment has increased. In fact, the latest data show nutrition is strong. In 2014, President Sall launched that progress against hunger has been nil: 24.5 percent the Emerging Senegal Plan with the goal of taking in 1991 and 24.6 percent in 2015. Undernourishment is Senegal to emerging country status by 2035 through a measure of food security rather than nutrition, howev- improving the well-being of the population and guar- Evolution of Nutrition Policy in Senegal 39 anteeing access to social services. In 2015, Senegal Ahead of the launch of the new SDGs, in 2010 the joined the SUN Movement Executive Committee. WHA announced six priority nutrition indicators and targets for 2025,33 which served to align the post-2015 Global and Regional. After decades of mounting ev- advocacy efforts among global nutrition partners. idence of the need for global action in nutrition, this Soon after, in 2012, the UN launched the global Zero period was marked by several important transitions. Hunger Challenge to galvanize actions to “end hunger, Global partners were at once galvanizing to take ac- eliminate all forms of malnutrition, and build inclusive tion in the few years remaining before the close of the and sustainable food systems.” Building off the Zero MDGs; looking backward to take stock and assess Hunger targets and more regionally specific, the Glob- what was accomplished; and looking forward to what al Alliance for Resilience (AGIR) was also launched was next after the 2015 deadline. in 2012, with the goal of “foster[ing] improved syn- ergy, coherence and effectiveness in support of Although the nutrition community had been lauding the resilience initiatives in the 17 West African and Sahe- importance of multisectoral approaches for nearly 50 lian countries” through establishing a common results years, newfound resurgence was generated by the publi- framework. cation of the Lancet Series on Maternal and Child Nutrition (2013). This follow-up to the landmark 2008 series high- During this period, on the heels of global momentum lighted the limitations of reducing stunting through the for nutrition generated by the SUN Movement and scale-up of nutrition-specific interventions alone and re- the launch of the SDGs, new efforts arose to: (1) es- emphasized the need for nutrition-sensitive interventions timate the costs of scaling up nutrition (World Bank in key sectors. In creating an at-scale community-based 2010); (2) establish clear commitments from donors multisectoral platform for nutrition, Senegal did what few and governments; (3) hold donors and governments other countries managed to do. Senegal was a leader accountable for commitments made; and (4) raise not only in having achieved remarkable reductions in new funding for nutrition through innovative financing stunting, but in the knowledge gained through having in- mechanisms from organizations such as the Clinton stituted an effective collaborative system that had been Foundation, the Bill & Melinda Gates Foundation, the sustained for nearly two decades. All eyes turned to Sen- Children’s Investment Fund Foundation (CIFF), and egal and other rare success stories (such as Peru) in an most recently, the Power of Nutrition. In 2013, the Unit- effort to replicate their success. ed Kingdom, Brazil, and CIFF hosted the Nutrition for Growth Summit in London “to bring together business Also during this period was the emergence of anoth- leaders, scientists, governments and civil society to er global trend: burgeoning rates of overweight and make the political and financial commitments needed obesity. Popularly perceived to be a problem only in to prevent undernutrition, enabling people and na- high-income populations, during this period the Dou- tions to prosper.” In 2014, the first in a series of Global ble Burden of Malnutrition (DBM)—the coexistence of Nutrition Reports was published to “track[] worldwide undernutrition and overweight and obesity in the same progress in improving nutrition status, identif[y] bottle- population, largely as a result of changing lifestyles and necks to change, highlight[] opportunities for action, food systems—was acknowledged as another mani- and contribute[] to strengthened nutrition account- festation of the challenge of malnutrition. The global ability.” (IFPRI 2014, xiv). The Global Nutrition Report emergence of the DBM and its link to noncommuni- motivated an initiative among the SUN Donor Network cable diseases, and the scale-up of nutrition-sensitive to establish a common and systematic approach to interventions including emphasis on engaging the calculating and tracking contributions to nutrition. private sector,32 were key themes highlighted at the Second International Conference on Nutrition (ICN2) Growing evidence on the combined impact of nutri- in 2014, 22 years after the first ICN in 1992. tion and early stimulation on brain development has 40 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal induced a shift among global partners toward a broad- Policy Document, also in 2011, and the Health Cover- er focus on Early Childhood Development (ECD), as age Strategic Plan (PSD-CMU) in 2013, constituting signaled by the launch in 2016 of the World Bank/ crucial components of the development of universal UNICEF Initiative for Investing in the Early Years. health care in Senegal, including the strengthening of Packaging nutrition under an ECD umbrella reinforces free services for children under five. convergence toward multisectoral approaches. Institutions. The institutional arrangements and stew- ardship for nutrition have not changed since 2001. Nutrition Policy During this time there have been three National Coor- dinators of CLM. Despite competition among partner Policies. The transition in leadership from President ministries for the limited nutrition budget, which led to Abdoulaye Wade to President Macky Sall in 2012 a brief period of sectorial strife, the principle of inclu- closed a chapter in which nutrition policy benefitted siveness has only been reaffirmed. The early success from unusually high political visibility. Global recogni- of PRN reinforced commitment at all levels, and min- tion has translated into increased funding for nutrition istries are starting to see how they can use the PRN’s in Senegal; the government’s financial commitment to structures to accomplish their own sector-specific nutrition—both in total nutrition spending and nutrition goals (Garrett and Natalicchio 2011). spending as a proportion of the overall national bud- get—is also increasing. Yet nutrition policy in Senegal Preparation of the new PSMN has once again brought is in a period of transition. Progress against global tar- all stakeholders to the table to look holistically at the gets has stagnated and challenges remain, including problem of malnutrition in Senegal and together iden- limited capacity to deliver and monitor results through tify strategies and priorities for addressing it. In this multisectoral engagement and inadequate funding. In way, CLM continues to function as the primary forum 2015, the DPNDN outlined the new vision. Currently un- for multisectoral collaboration, the “glue” to “bring part- der development—with engagement of global partners ners together and eliminate barriers to reducing the such as the World Bank and UNICEF—is the PSMN, burden of malnutrition.”34 Among the factors for suc- which will operationalize the DPNDN and be the princi- cessful engagement are strong role definition and clear pal tool for nutrition coordination going forward. lines of accountability. In Senegal, nutrition is a shared responsibility, and each sector has an important con- Also during this period, the Ministry of Health continued tribution to make in terms of action and financing. to build upon the operative framework for nutrition ser- vice delivery and published the Prise en Charge de la Programs. The World Bank funding for PRN came to Malnutrition Aigué (Community Management of Acute end in 2014, but Senegal leveraged the success of Malnutrition) (PECMA) protocol in 2013; the Nutrition the program to raise funds from other donors. Since Monitoring Guide in 2014; and the Communication instituting a budget line item for nutrition, government Strategy for the Promotion of Exclusive Breastfeeding contributions to nutrition have increased to CFAF 3 bil- in 2015. Efforts at decentralization—beginning in 1964 lion in 2016. PRN continues to be Senegal’s flagship and continuing, in 1972, with the creation of rural com- nutrition program. Building on the results achieved munities and, in 1996, with the transfer of power to local through the scale-up of CMAM, PCIME-C, and Growth authorities—culminated, in 2014, with a phase of wide- Monitoring and Promotion through decentralized spread communalization. Policies in other sectors with structures, Phase III (“consolidating achievements”), implications for nutrition launched during this period with continued support from international partners, include the Economic and Social Policy Document in undertakes to: (1) scale up nutrition-specific interven- 2011, which became the basis for increased govern- tions at the community level, notably those targeting ment financial ownership of PRN, the Social Protection the first 1,000-day window from pregnancy to two Evolution of Nutrition Policy in Senegal 41 years of age; and (2) institutionalize the multisectoral Key Themes planning, implementation, and financing of nutri- tion-sensitive interventions. To a large degree, the story of this generation is yet to be written. With Senegal at the forefront of global Projects such as MI’s Integrated Nutrition Project in nutrition policy, there are not many models of success. Kolda and Kédégou Regions (PINKK), MI’s Zinc Al- Senegal’s progress depends on the success of the liance for Child Health (ZACH) project, and USAID’s PSMN and the ability of global partners to raise ade- Health Services Improvement Program, Community quate financing. Health Program, and Yaajeende Project, contribute to strengthening Senegal’s system for delivery of nutri- The key nutrition-related policies and influences for tion-specific and nutrition-sensitive services. this generation are listed in box 5. BOX 5: Nutrition-Related Policies and Influences during the Multisectoral Approach Generation Policies Key National Influences • Social Protection Policy Document (2011) • DHS (2010–11) • Economic and Social Policy Document (2011) • 21st Annual Martin J. Forman Memorial Lecture • Senegal joins the global SUN Movement (2011) (2011) • (NSESD) National Strategy for Economic and • SMART (Standardized Monitoring and Social Development (2013) Assessment of Relief and Transitions) Survey (2011) • PSD-CMU (2013) • Election of President Macky Sall (2012) • PECMA protocol (2013) • SMART Survey (2012) • Emerging Senegal Plan Priority Action Plan (2014) • Regional SMART Survey (yearly) • Nutrition Monitoring Guide (2014) • Flooding and drought (2012) • Communication Strategy for the Promotion of Exclusive Breastfeeding (2015) • DHS (continued 2012–13) • DPNDN (2015) • SMART Survey (2014) • Senegal joins the SUN Executive Committee (2015) • DHS (continued 2014) • PSMN (in development) Key Regional/Global Influences Institutions • Zero Hunger Challenge (2012) • (DAN) Division de l’Alimentation de la Nutrition • AGIR (2012) (Division of Food and Nutrition) and (DSE) • (NASAN) New Alliance for Food Security and Division de la Survie de l’Enfant (Division of Child Nutrition (2013) Survival) replace DANSE (2012) • Lancet Series on Maternal and Child Nutrition • Annual nutrition budget increase from CFAF 1.4 (2013) billion in 2011 to CFAF 3.6 billion (2016) • Global Nutrition Report (2014) • ICN2 (2014) Programs • Power of Nutrition Partnership (2014) • PRN (continued) • Political Declaration and Framework for Action to • Yaajeende (continued) Tackle Hunger and Obesity (2014) • (ZACH) Zinc Alliance for Child Health (2012) • Global Nutrition Report (2015) • (PAQUET) Improvement of Quality Education, • SDGs (2016) Equity and Transparency Program (2012) • Global Nutrition Report (2016) • Results-Based Financing (2013–18) • World Bank/UNICEF Initiative for Investing in the • (PINKK) Integrated Nutrition Project for the Kolda Early Years (2016) and Kedougou Regions (2015) 42 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 7 Conclusion T he course of nearly sixty years in the evolution of Wade, who became Senegal’s top nutrition champion. nutrition policy in Senegal can be traced through Under the Wade administration, the damage done in six themes, whose seeds were planted in the the dissolution of the institutional arrangements for nu- earliest days of the republic: nutrition championship, trition was righted. Hard lessons learned from CNLM institutional ownership, multisectoral coordination and and PNC were applied. Institutional ownership of nu- collaboration, community ownership, integrated ser- trition changed to the newly created CLM, and PRN vices and delivery platforms, and partner engagement. became Senegal’s flagship nutrition program. Through a participatory and multisectoral approach, decen- There are two significant turning points for nutrition tralized delivery of preventive nutrition services and policy in Senegal. First was the social and political cri- integrated platforms, and a spirit of shared responsibil- sis in the early 1990s, which resulted, in large part, ity and shared success, an effective system was built from structural adjustment reforms that exacerbated with the results to prove it. an already deteriorating nutrition situation, revealed the inadequacy of the health system to address it, As Senegal hovers on the cusp of yet another major and ultimately resulted in creation of the CNLM and transition for nutrition policy, its strengths are evident. PNC. Changing institutional ownership of nutrition Institutionally, the CLM provides an effective plat- from the Ministry of Health to a government agency form for coordination at national and local levels, with with no experience implementing health projects was clear lines of accountability, and partner commitment a radical—and political—move. For a period, while the and collaboration. Leaders have managed to lever- system readjusted, key institutional relationships were age positive results to mobilize additional financing severely fractured. Although not at all clear at the time, from external donors and increased government fi- in hindsight it seems evident that the dramatic change nancing for nutrition. The commitment to building off was necessary to build back stronger. gains already made in improving social services and advancing human capital remains strong in the Sall The second key turning point in nutrition policy in Sen- administration. The DPNDN, a vision for nutrition poli- egal was the election in 2000 of President Abdoulaye cy that will carry Senegal well into the SDGs, has been Evolution of Nutrition Policy in Senegal 43 launched, and the PSMN is under development with ute. A core strength is that the network is already in the engagement and support of all partners. place. All regions in Senegal are covered with an entry point through local leaders who are able to convene The remarkable drop in stunting by approximately actors in all sectors. The process of developing the half during the period of the MDGs is a direct result PSMN has examined what each sector is doing in its of Senegal’s doing more for nutrition and doing it core mission and identified the links with nutrition, op- better. However, as noted, progress toward nutrition portunities for fundraising, and specific areas in need targets has stagnated and challenges remain, includ- of capacity building. In addition, each region requires ing limited capacity to deliver and monitor results an assessment of its nutrition situation and key deter- through multisectoral engagement and inadequate minants, the development of locally relevant plans for funding. PRN reaches approximately 70 to 80 per- action, the identification of local capacities that need to cent of children under five with quarterly nutrition be strengthened, and sources of funding. screening; however, monthly growth monitoring and promotion activities reach only about 30 percent of By and large, nutrition has always been high on the children under two. Senegal needs more pronutrition political agenda in Senegal. Global visibility and prom- interventions through other sectors, improved target- inence as a leader in nutrition hit a peak in 2010–11. ing to identify areas of highest burden, and increased The lack of a high-level champion and nutrition’s sub- effort to extend services to hard-to-reach areas. To sequent drop on the political agenda since the end meet WHA/SDG goals, more financial resources are of the Wade administration is another challenge for needed. nutrition leadership in Senegal during this period of transition. If history is any indication, this and many Mainstreaming nutrition is Senegal’s biggest challenge other challenges will be overcome in yet unfore- for the next 10 years, and all sectors need to contrib- seen—but no doubt remarkable—ways. 44 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal APPENDIX A Senegal Nutrition Policy Timeline Start English Française 1948 Universal Declaration of Human Rights Déclaration Universelle des Droits de l’Homme 1954 Maternity Leave Regulation Règlementation du congé de maternité 1956 (ORANA) Research Organization for Food and (ORANA) Organisme de Recherche sur l’Alimentation et la Nutrition in Africa Nutrition Africaines 1960 (CRENs) Centers of Recovery and Nutritional (CREN) Centres de Récupération et d’Education Nutritionnelle Education 1960 Independence of Senegal Indépendance du Sénégal 1960 Presidency of Léopold Sédar Senghor Présidence sous Léopold Sédar Senghor 1961 1st PQDES 1er PQDES 1963 Constitution La Constitution 1963 (ITA) Food Technology Institute (ITA) Institut de Technologie Alimentaire 1964 Decentralization reforms Réformes de la décentralisation 1965 2nd PQDES 2ème PQDES 1965 (BANAS) Office for Food and Applied Nutrition in (BANAS) Bureau National d’Alimentation et de la Nutrition Senegal Appliquée au Sénégal 1968 West African Conference on Nutrition and Child Conférence Ouest Africaine sur la Nutrition et l’Alimentation de Feeding l’Enfance 1968 Sahelian drought Sécheresse au Sahel 1969 3rd PQDES 3ème PQDES 1972 Decentralization reforms Réformes de la Décentralisation 1973 4th PQDES 4ème PQDES 1973 (PPNS) Nutrition and Health Protection Program (PPNS) Programme de Protection Nutritionnelle et Sanitaire 1975 Programme Santé Sécheresse Programme Santé Sécheresse 1977 5th PQDES 5ème PQDES 1977 Food Investment Strategy 1977–85 Stratégie d’Investissement dans l’Alimentation 1977–85 1978 Alma Ata Declaration Déclaration d’Alma Ata (continued on next page) Evolution of Nutrition Policy in Senegal 45 (continued) Start English Française 1979 Stabilization Program Programme de Stabilisation 1979 (CANAS) Committee of Food and Nutritional (CANAS) Comité d’Analyse Nutritionnelle et Alimentaire au Analysis in Senegal Sénégal 1981 6th PQDES 6ème PQDES 1981 International Code of Marketing of Breastmilk Code international de commercialisation des substituts du lait Substitutes maternel 1981 Presidency of Abdou Diouf Présidence sous Abdou Diouf 1982 World Bank Rural Health Project Projet de Santé Rurale de la BM 1983 Iringa Project (Tanzania) Projet Iringa (Tanzanie) 1985 7th PQDES 7ème PQDES 1985 Adjustment Program Programme d’Ajustement 1986 Publication of Sommer et al., “Impact of Vitamin A Publication de Sommer et al., “Impact de l’apport de Supplementation on Childhood Mortality” suppléments en vitamine A sur la mortalité infantile” 1986 DHS 1986 EDS 1986 1988 (SANAS) Nutrition and Food Service of Senegal (SANAS) Service de l’Alimentation et de la Nutrition Appliquée du Sénégal 1989 8th PODES 8ème PODES 1989 Nutritional Rehabilitation and Surveillance Programme de Réhabilitation et de Surveillance Nutritionnelle Program 1989 (PSMI/PF) Maternal and Child Health and Family (PSMI/PF) Programme de Santé Maternelle et Infantile et de Planning Program Planification Familiale 1990 Innocenti Declaration on the Protection, Déclaration d’Innocenti en faveur de la Protection, la Promotion and Support of Breastfeeding Promotion et le Soutien à l’Allaitement 1990 World Summit for Children Sommet Mondial sur l’Enfance 1990 (PCIME) Integrated Management of Childhood (PCIME) Prise en Charge Intégrée des Maladies de l’Enfant Illness 1990 UNICEF Nutrition Conceptual Framework Cadre conceptuel de la nutrition de l’UNICEF 1992 (ICN) International Conference on Nutrition (CIN) Conférence Internationale sur la Nutrition 1992 DHS 1992–93 EDS 1992–93 1994 Salt Iodization Strategy to Fight IDD Stratégie d’iodation du sel pour lutter contre les troubles liés à la carence en iode 1994 Interministerial Decree Establishing the Arrêté Interministériel fixant les conditions de Conditions for Marketing Breastmilk Substitutes commercialisation des substituts du lait maternel 1994 Baby-Friendly Hospital Initiative L’Initiative Hôpitaux Amis des Bébés 1994 USAID/BASICS USAID/BASICS 1994 Salt Iodization Project Projet d’Iodation du Sel 1994 (CNLM) National Committee for the Fight against (CNLM) Commission Nationale de Lutte contre la Malnutrition Malnutrition 1994 (AGETIP) Executing Agency for Works of Public (AGETIP) Agence d’Exécution des Travaux d’Intérêt Public Interest Against Unemployment 1994 (SNAN) National Service of Food and Nutrition (SNAN) Service National de l’Alimentation et de la Nutrition 1994 Devaluation of the CFA franc & resulting urban Dévaluation du franc CFA suivie d’agitation urbaine unrest 1994 Publication of Pelletier et al., “A Methodology Publication de Pelletier et al., “A Methodology for Estimating for Estimating the Contribution of Malnutrition to the Contribution of Malnutrition to Child Mortality in Developing Child Mortality in Developing Countries” Countries” 1995 (PNC) Community Nutrition Project (PNC) Projet de Nutrition Communautaire 1995 World Summit for Social Development Sommet de Copenhague pour l’Elimination de la Pauvreté Copenhagen (continued on next page) 46 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal (continued) Start English Française 1996 9th PODES 9ème PODES 1996 (PCIME) Integrated Management of Childhood (PCIME) Prise en Charge Intégrée des Maladies de l’Enfant Illness 1997 National Plan of Action for Nutrition Plan National d’Action pour la Nutrition 1997 (AEN) Essential Nutrition Actions framework (AEN) Cadre de Actions Essentielles en Nutrition 1997 DHS 1997 EDS 1997 1998 (PAIN) Package of Integrated Nutrition Actions (PAIN) Paquet d’Activités Intégrées de Nutrition et AEN and AEN 1998 (CNSA) National Food Security Council (CNSA) Conseil National de Sécurité Alimentaire 1999 National Vaccination Days and National Journées Nationales de Vaccination et Journées Nationales Micronutrient Supplementation Days de Supplémentation en Micronutriments 1999 DHS 1999 EDS 1999 2000 (DSRP) Poverty Reduction Strategy Paper (DSRP) Document de Stratégie pour la Réduction de la Pauvreté 2000 Decree Mandating Universal Salt Iodization Décret portant sur l’iodation universelle du sel 2000 Millennium Development Declaration and the (OMD) Objectifs du Millénaire pour le Développement MDGs (2000–15) (2000–15) 2000 Global Strategy for the Prevention and Control of Stratégie Mondiale pour la prévention et la lutte contre les Noncommunicable Diseases maladies non transmissibles 2000 Presidency of Abdoulaye Wade Présidence sous Abdoulaye Wade 2001 Revised National Constitution Révision de la Constitution nationale 2001 (LPDN) Policy Letter on Nutrition and Development (LPDN) Lettre de Politique de Développement de la Nutrition 2001 Nutrition Standards and Protocols Normes et Protocoles en Nutrition 2001 (PDEF) Ten-Year Education and Training (PDEF) Programme Décennal de l’Education et de la Program Formation 2001 (CLM) Nutrition Coordination Unit (CLM) Cellule de Lutte contre la Malnutrition 2001 (BEN) National Executive Bureau (BEN) Bureau Exécutif National 2001 (BER) Regional Executive Bureau (BER) Bureau Exécutif Régional 2001 (AEC) Community Executing Agency (AEC) Agence d’Exécution Communautaire 2001 (NEPAD) New Partnership for Africa’s (NEPAD) Nouveau Partenariat pour le Développement de Development l’Afrique 2001 (CMAM) Community-Based Management of (PCMA) Prise en Charge Communautaire de la Malnutrition Acute Malnutrition Aiguë 2001 Appointment of Biram Ndiaye as Coordinator of Coordonnateur de la CLM : Biram Ndiaye CLM 2002 10th PODES 10ème PODES 2002 (DSRP) Poverty Reduction Strategy Paper (DSRP) Document de Stratégie pour la Réduction de la Pauvreté 2002 PCIME Strategic Plan (2002–07) PCIME Plan Stratégique 2002–07 2002 (PDC) Communal Development Plan (PDC) Plan de Développement Communal 2002 (PNDL) National Program for Local Development (PNDL) Programme National de Développement Local 2002 (PRN) Nutrition Enhancement Program Phase I (PRN) Programme de Renforcement de la Nutrition Phase 1 (2002–05) (2002–05) 2002 (PCIME-C)) Community Integrated Management (PCIME-C) Prise en Charge Intégrée de la Maladie l’Enfant au of Childhood Illnesses Niveau Communautaire 2002 World Food Summit Sommet Mondial de l’Alimentation 2002 A World Fit for Children Un Monde digne des enfants 2002 PROFILES Senegal PROFILES Sénégal (continued on next page) Evolution of Nutrition Policy in Senegal 47 (continued) Start English Française 2003 (DANSE) Division of Food Nutrition and Child (DANSE) Division de l’Alimentation de la Nutrition et de la Survival Survie de l’Enfant 2003 Global Strategy for Infant and Young Child Stratégie Mondiale pour l’Alimentation du Nourrisson et de Feeding Jeune Enfant 2003 Maputo Declaration on Agriculture and Food Déclaration de Maputo sue l’Agriculture et la Sécurité Security alimentaire 2004 Copenhagen Consensus Consensus de Copenhague 2004 Global Strategy on Diet, Physical Activity and Stratégie mondiale sur l’alimentation, l’exercice physique et la Health santé 2005 Countdown to 2015 event in London Compte à rebours vers 2015 à Londres 2005 Paris Declaration and Accra Agenda for Action Déclaration de Paris et Agenda d’Accra pour l’Action 2005 DHS 2005 EDS 2005 2005 Macky Sall and Jacques Sylla, Letter to the Editor Lettre de Macky Sall et Jacques Sylla à l’éditeur du Lancet of the Lancet, “African Prime Ministers Take Lead : “Les Premiers Ministres africains aux commandes pour la in Child Survival” survie de l’enfant” 2006 (LPDN) Policy Letter on Nutrition and (LPDN) Lettre de Politique de Développement de la Nutrition Development (Revised) (Révisée) 2006 National Policy for Infant and Young Child Politique Nationale pour l’Alimentation du Nourrisson et du Feeding Jeune Enfant 2006 Program for the Enhancement of Fortification Programme de Renforcement de la Fortification Alimentaire 2006 (COSFAM) Committee for Food Fortification (COSFAM) Comité Sénégalais pour la Fortification des Aliments en Micronutriments 2006 (CTIUS) Technical Committee for USI (Universal (CTIUS) Comité Technique pour l’Iodation Universelle du Sel Salt Iodization) 2006 WHO Child Growth Standards: Methods and Normes OMS de Croissance de l’Enfant: Méthodes et Development Élaboration 2006 Repositioning Nutrition as Central to Repositionnement de la Nutrition comme point essentiel au Development développement 2007 11th DSRP 11ème DSRP 2007 Increase in nutrition line item in the national Augmentation de l’enveloppe budgétaire allouée à la nutrition budget 2007 (PNSE) National Plan for Child Survival (PNSE) Plan National de Survie de l’Enfant 2007 (PRN) Nutrition Enhancement Program Phase II (PRN) Programme de Renforcement de la Nutrition Phase 2 2007 Global Food Price Crisis Crise mondiale des prix de denrées alimentaires 2008 Appointment of Khadidiatou Dieng as Coordinator Coordonnatrice de la CLM : Khadidiatou Dieng of CLM 2008 Lancet Series on Maternal and Child Série du Lancet sur la malnutrition maternelle et infantile Undernutrition 2009 (PNDS) National Health Development Plan (PNDS) Plan National Développement Sanitaire et Social 2009 Decree Mandating Vitamin A Fortification of Oil Décret portant sur la fortification de l’huile en vitamine A 2009 Decree Mandating the Fortification of Wheat with Décret portant sur la fortification du blé avec du fer et de Iron and Folic Acid l’acide folique 2009 Comprehensive Africa Agriculture Development Programme Détaillé de Développement de l’Agriculture en Program Compact Afrique 2009 (NETS) Child Targeted Nutrition and Social (NETS) Projet de nutrition ciblée sur l’enfant et les transferts Transfers Program sociaux 2009 (NESA) Child Food and Nutrition Security Project (NESA) Project Nutrition Enfant et Sécurité Alimentaire 2009 Salt Iodization Project Projet d’Iodation du Sel 2010 National Child Survival Program Programme National de Survie de l’Enfant 2010 Yaajeende Yaajeende (continued on next page) 48 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal (continued) Start English Française 2010 (SUN) Scaling Up Nutrition Movement (SUN) Mouvement de Renforcement de la Nutrition 2010 WHA Resolution WHA63.23 on Infant and Young Résolution de l’AMS 62–23 sur la Nutrition des Nourrissons et Child Nutrition des Jeunes Enfants 2010 Senegal Ministry of Economy and Financing Prix Alpha du Ministère de l’Economie et des Finances à PRN Alpha Award given to PRN 2010 DHS 2010–11 EDS 2010–11 2011 Social Protection Policy Document (2011–15) Document de Politique de Protection Sociale (2011–15) 2011 Economic and Social Policy Document (2011–15) Document de Politique de développement économique et social (2011–15) 2011 (PNIA) National Agricultural Investment Program (PNIA) Programme National d’Investissement Agricole (2011–15) (2011–15) 2011 Health Services Improvement Program Programme de renforcement des services de santé 2011 Community Health Program Programme de santé communautaire 2011 SUN country Pays SUN 2011 SMART Survey 2011 Enquête SMART 2011 2012 (ZACH) Zinc Alliance for Child Health (ZACH) Projet Zinc Alliance for Child Health 2012 (PAQUET) Improvement of Quality Education, (PAQUET) Programme d’Amélioration de la Qualité de Equity and Transparency Program l’Enseignement, de l’Équité et de la Transparence 2012 Zero Hunger Challenge Programme Zéro Faim 2012 (AGIR) Global Alliance for Resilience—Sahel and (AGIR) Alliance Globale pour la Résilience—Sahel et Afrique West Africa de l’Ouest 2012 Appointment of Abdoulaye Ka as Coordinator of Coordonnateur CLM: Abdoulaye Ka CLM 2012 Presidency of Macky Sall Présidence sous Macky Sall 2012 SMART Survey 2012 Enquête SMART 2012 2012 DHS 2012–13 EDS 2012–13 2013 (NSESD) National Strategy for Economic and (SNDES) Stratégie Nationale de Développement Economique Social Development (2013–17) et Social (2013–17) 2013 (PSD-CMU) Health Coverage Strategic Plan (PSD-CMU) Plan Stratégique de Développement de la Couverture Maladie 2013 PECMA protocol Protocole de PECMA 2013 Nutrition for Growth Summit, London Sommet sur la Nutrition pour la Croissance, Londres 2013 (NASAN) New Alliance for Food Security and (NASAN) Nouvelle Alliance pour la Sécurité Alimentaire et Nutrition Nutritionnelle 2013 Lancet Series on Maternal and Child Nutrition Série du Lancet sur la nutrition maternelle et infantile 2014 Emerging Senegal Plan Priority Action Plan Plan Sénégal Emergent Plan d’Actions Prioritaires (2014–18) (2014–18) 2014 Nutrition Monitoring Guide Guide de surveillance nutritionnelle 2014 (PRN) Nutrition Enhancement Program Phase III (PRN) Programme de Renforcement de la Nutrition Phase 3 2014 (ICN2) Second International Conference on Nutrition (CIN2) Deuxième Conférence Internationale sur la Nutrition 2014 Political Declaration and Framework for Action to Déclaration politique et Cadre d’action contre la famine et Tackle Hunger and Obesity l’obésité 2014 Global Nutrition Report 2014 Rapport Mondial sur la nutrition 2014 2014 SMART Survey 2014 Enquête SMART 2014 2014 DHS 2014 EDS 2014 2015 (DPNDN) National Policy for the Development of (DPNDN) Document de Politique Nationale de développement Nutrition (2015–25) de la Nutrition (2015–25) 2015 Policy Document of Health/Nutrition/Environment Document de Politique Sanitaire/Nutritionnelle/ in the Education System Environnementale du Système Educatif (continued on next page) Evolution of Nutrition Policy in Senegal 49 (continued) Start English Française 2015 Communication Strategy for the Promotion of Stratégie Communication pour la Promotion de l’AME Exclusive Breastfeeding 2015 (PINKK) Integrated Nutrition Project for the Kolda (PINKK) Projet Intégré de Nutrition Dans les Régions de Kolda and Kedougou Regions et de Kédougou 2015 (SDGs) Sustainable Development Goals (ODD) Objectifs de Développement Durable des Nations Unies 2015 Global Nutrition Report 2015 Rapport Mondial sur la nutrition 2015 2016 (PSMN) Multisectoral Strategic Nutrition Plan (PSMN) Plan Stratégique Multisectoriel de la Nutrition 2016 World Bank/UNICEF Initiative for Investing in the Initiative BM/UNICEF pour l’investissement dans l’enfance Early Years 2016 Global Nutrition Report 2016 Rapport Mondial sur la Nutrition 2016 50 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal Endnotes 1. Joint Child Malnutrition Estimates, UNICEF (Unit- ing in 1965; the Service de l’Alimentation et de ed Nations Children’s Fund), WHO (World Health la Nutrition Appliquée du Sénégal (Nutrition and Organization) and World Bank (accessed 2017), Food Service of Senegal) (SANAS) in the 1980s; http://datatopics.worldbank.org/child-malnutrition/. the Service National de l’Alimentation et de la 2. There have been several attempts to characterize Nutrition (National Service of Food and Nutrition) the generations of nutrition policy in Senegal. This (SNAN) in the 1990s; the Division de l’Alimen- report draws upon those first introduced in Ndiaye tation, de la Nutrition et de la Survie de l’Enfant (2010). (Division of Food, Nutrition and Child Survival) 3. Specifically, the mandate for ORANA is the fol- (DANSE) in the mid-2000s; and, as of 2012, the lowing: “The role of ORANA is to know the people Division de l’Alimentation et de la Nutrition (the of the countries in which it is based, their eating Division of Food and Nutrition) (DAN), separate habits, their diseases, their economic and so- from the Division of Child Survival (Division de la cial status, and their beliefs. It also has the role Survie de l’Enfant) (DSE), under the Directorate of of assessing the actual food consumption and Reproductive Health and Child Survival. nutritional status of populations and determining 6. The name of the ministry responsible for nutrition the deficiencies that have repercussions on their would also change over time, from the Ministère health status.” (Kokou-Alonou 2007). de la Santé et des Affaires Sociales (Ministry of 4. The original member states were: Benin (formerly Health and Social Affairs) at independence in the Dahomey), Burkina Faso (formerly Upper Volta), 1960s, to the Ministère de la Santé Publique (Min- Côte d’Ivoire, Mali (formerly French Sudan), Maurita- istry of Public Health) in the 1970s, to the Ministère nia, Niger, and Senegal. Guinea and Togo (formerly de la Santé et de la Prévention (Ministry of Health French Togoland) joined as member states later. and Social Welfare) in the 2000s, and, as of 2012, 5. Over time, the nutrition unit would have many Ministère de la Santé et de l’Action Sociale (Minis- names: the Bureau National d’Alimentation et de try of Health and Social Action). la Nutrition Appliquée au Sénégal (Office for Food 7. It was recognized at the time that facility-based cu- and Applied Nutrition in Senegal) (BANAS), start- rative care was not an effective or viable solution Evolution of Nutrition Policy in Senegal 51 in real-world conditions: “These experiments have This is also a matter of coordination. The National always been made in the best possible scientific Nutrition Service, or whatever its title may be, is conditions: these children have been treated and unique. Very often, this service is attached to the conditioned away from their homes. Under those Ministry of Health but it is not mandatory that it be circumstances, we do what we want with a child; this way; it is a service which can be attached to but every time that we have undertaken the experi- the highest echelon possible, even to the Secre- ment in village surroundings, the benefits obtained tariat of the Presidency of the Republic” (Republic were less evident and diluted in many. I think that of Senegal and USAID 1968). the solution here is to be found at the village level 11. The importance of other sectors, such as agricul- in the context of rural markets” (Republic of Sene- ture, to improving nutrition outcomes was already gal and USAID 1968). well understood (“[The] fight against nutritional 8. The primary purpose of the rural day care centers deficiencies and the development of food crops was to provide a safe place to keep children while are primarily the responsibilities of the Health their mothers worked in the field: “Women have Department and the Agriculture Department; but organized, with help from the instructors, village these operations demand education, which should nurseries for which they are materially and morally be viewed in its broadest sense…” (Republic of responsible, so that the children would not be left Senegal and USAID 1968), as was the need for to themselves during that time” (Republic of Sene- multisectoral collaboration (“The improvement of gal and USAID 1968). nutrition for the populations, as well as the strug- 9. In this UNESCO-supported project, communi- gle against malnutrition, demands the cooperation ty volunteers were trained in health, agriculture, of a broad spectrum of expertise and all available and human development and carried out activ- goodwill. It cannot consist of purely sectorial oper- ities to promote good nutrition practices in their ations; it necessitates teamwork and planning at communities: “During the phases of first degree different levels. Therefore, it is desirable that the instruction where male and female instructors governments treat this problem as an intermin- are trained, practical sessions are provided, as isterial matter and that it be included in regular well as discussions and examples of decisions to meetings where experts from different fields and be made on short notice. Second degree class- different services would meet to harmonize con- es complete the training of female instructors in cepts and operations. In addition, representatives nutrition of infants, pregnant women and nursing of voluntary agencies can probably contribute to mothers. Subsequently, these female instructors these meetings” (Republic of Senegal and USAID meet with the women of their villages and neigh- 1968)). borhoods on a voluntary basis in order to convey, 12. Failure to achieve marked improvement in nutrition in a lively fashion, the acquired knowledge, along status after a decade of nutrition programming was with dietary advice” (Republic of Senegal and US- met with frustration: “Past efforts of the government AID 1968). to increase local food production and raise nutrition 10. High-level debates about the appropriate place- standards have met with relatively little success. No ment of the nutrition unit in Senegal would continue substantive programs to make a permanent impact for decades to come: “I have often heard mention on malnutrition among the most needy populations being made of a Nutrition Division located in the have been successful” (USAID 1980). Department of Rural Economy, or of a Nutrition 13. There were numerous nutrition-related programs Division located in a Department of so forth, and being carried out in Senegal with funding from the I believe that it is necessary to Coordination, and donor community during this period: “UNDP has differentiate between a Nutrition Division within a financed a number of projects in food crop and Department and the National Nutrition Service. fishery development, and an eight-year project 52 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal to establish and develop ITA. FAO has provided well as institutional problems encountered within funds, equipment and training, in health and nu- the Ministry” (Ndiaye 2007). trition centers-and health posts, rural maternities 19. Early World Bank health projects in Senegal with nu- and village pharmacies, and for a pilot nutrition trition components included the Rural Health Project project in the Sine Saloum region. WHO is as- (1982–91); PNC (1995–2001); the Integrated Health sisting several small projects for development of Sector Development Project (1998–2005); and the health services training of medical and paramedi- HIV/AIDS Prevention & Control Project (2002–10). cal personnel, combatting infectious diseases and 20. The countries participating in the 1992 ICN were improving environmental health. UNICEF works obligated to develop national plans of action based primarily in rural maternities and health posts. on ICN strategies. As was typical, Senegal’s 1997 WFP is currently operating six supplementary National Plan of Action for Nutrition was expansive feeding projects in primary and technical schools and unfunded. and rural training centers, and food-for-work 21. Senegal was a late adopter—among the very last projects in Sine Saloum and Eastern Senegal” in West and Central Africa—of the twice-yearly vi- (USAID 1980). tamin A supplementation campaigns. 14. Documents at the time highlight the overemphasis 22. The Paris Declaration and Accra Agenda for Ac- on curative rather than preventive nutrition inter- tion of 2005 committed donors to five principles: vention: “Nutrition problems are studied primarily as ownership, alignment, harmonization, results, and a public health issue with the health sector concen- mutual accountability. trating heavily on curative rather than preventive 23. The nutrition budget started in 2002 at US$300,000 care, on large urban hospitals rather than rural per year and increased to US$2.7 million in 2007 community services, and on training physicians and US$5.7 million in 2015. rather than village health workers” (USAID 1980). 24. CLM began in 2002 with six regional offices, re- 15. The limitations of current nutrition interventions duced to three in 2007. were well understood: “The value of supplemen- 25. Phase I (2002–06) development objectives were tary feeding has been increasingly challenged in to: (1) extend nutrition and growth promotion inter- terms of its effect on improving child growth. Vege- vention into rural areas; (2) consolidate and sustain table gardens have met with very limited success” the results gained with the earlier PNC, which con- (World Bank 1982). tributed to reversing the negative trend in nutritional 16. Direct comparisons between child anthropomet- status among children under three in urban areas; rics for 1986 and following years cannot be made and (3) strengthen the institutional capacity of the because the 1986 anthropometrics were collected CLM as well as that of its partners in the public and for children under three, whereas anthropometrics private sector to develop, implement, and moni- for the following years were collected for children tor multisectoral nutrition activities. PRN Phase I under five. comprised three components: Component I: com- 17. Nutrition had high prominence in national policies munity nutrition and growth promotion; Component during this period, but financing did not keep pace: II: capacity building and monitoring and evaluation; “The [government of Senegal] seems to have the and Component III: program management. “political will,” the commitment, to solve its prob- 26. The Phase II (2007–11) development objective lems of hunger and malnutrition, but it does not was to expand access to and enhance nutritional have the resources to do so” (USAID 1980). conditions of vulnerable populations, in particular 18. Support for nutrition within the Ministry of Health those affecting growth of children under five in poor was weak: “[The National Nutrition Program] in the urban and rural areas. PRN Phase II comprised early 1990s … resulted in few concrete activities three components: Component 1: communi- due to the lack of political will and resources as ty-based nutrition; Component 2: multisectoral Evolution of Nutrition Policy in Senegal 53 support to nutrition; and Component 3: support to of acute respiratory infection, diarrhea, measles, implementation, monitoring and evaluation of the malaria, malnutrition, and other serious infections; nutrition development policy. counseling on feeding problems; iron for treatment 27. Although the original World Bank Adaptable Pro- of anemia; and antihelminthic treatment. gram Lending instrument and the three phases of 29. Anthropometric outcomes (prevalence of under- the PRN were aligned for a total of 10 years, the weight and severe underweight) were measured second phase of the PRN started a year late and in PRN Phase I, but removed for Phase II. lasted for 8 to 9 years, and the third phase started 30. PRN also includes pilot projects such as the Pro- in earnest only in 2015, 13 years after the launch jet d’Appui à la Sécurité Alimentaire des Ménages of the PRN. Phase III is expected to take far longer Vulnérables (Food Security Support for Vulnera- than the two to three years originally anticipated. ble Households Project), which aims to enhance 28. Illness prevention and growth promotion interven- the impact of nutrition activities by improving the tions at the home and community level comprise: availability and accessibility of agricultural and community or home-based promotion of appropri- livestock products. ate infant feeding practices; peer counseling for 31. The Senegal Senate was temporarily abolished breastfeeding and complementary feeding; use in order, purportedly, to pay for the emergency of insecticide-treated bed nets; and appropriate response. infection control practices. Illness prevention and 32. In particular, NASAN, launched in 2013, aims to growth promotion interventions at the health ser- “engage the private sector in nutrition-sensitive vices level comprise: vaccinations; micronutrient interventions and mobilize national and foreign supplementation; and health worker counseling private investments to stimulate and support the for breastfeeding and appropriate complementary agricultural sector.” feeding. Curative care interventions at the home 33. The six indicators and targets are under-five and community level comprise: early recognition stunting, anemia in women of reproductive age, and home management of illness; appropriate low birth weight, childhood overweight, exclusive care seeking; and adherence to treatment rec- breastfeeding, and under-five wasting. ommendations. Curative care interventions at the 34. Abdoulaye Ka, National Coordinator of the CLM, health services level comprise: case management interview with the author, August, 2016. 54 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal References Abosede, O., and J. McGuire. 1991. “Improving Wom- Lancet. 2005. “Editorial: The Second Child Survival en’s and Children’s Nutrition in Sub-Saharan Revolution.” Lancet 365 (9478): 2152. Africa: An Issues Paper.” Policy, Research, and External Affairs Working Paper WPS 723, World Lancet Series on Maternal and Child Undernutrition. Bank, Washington, DC. 2008. Amsterdam: Elsevier Inc. Garrett, J., and M. Natalicchio, eds. 2011. Working Lancet Series on Maternal and Child Nutrition. 2013. Multisectorally in Nutrition. Washington, DC: Inter- Amsterdam: Elsevier Inc. national Food Policy Research Institute. Marek, T., I. Diallo, B. Ndiaye, and J. Rakotosala- (IFPRI) International Food Policy Research Institute. ma. 1999. “Successful Contracting of Prevention 2014. Global Nutrition Report 2014: Actions and Services: Fighting Malnutrition in Senegal and Accountability to Accelerate the World’s Progress Madagascar.” Health Policy and Planning 14 (4): on Nutrition. Washington, DC: IFPRI. 382–89. Ka, Abdoulaye. 2011. “Nutrition in Senegal: Achieve- Mehra, R., K. Kurz, and M. Paolisso. 1992. “Child ments and Prospects” (21st Annual Martin J. Care Options for Working Mothers in Developing Forman Lecture). http://www.ifpri.org/event/21st-an- Countries.” International Center for Research on nual-martin-j-forman-memorial-lecture. Women, Washington, DC. Kokou-Alonou, B. 2007. “La Politique Sanitaire de Ndiaye, A.I. 2010. “Sénégal—Comprendre les facteurs l’Organisation de Coordination et de Coopera- politiques et institutionnels conduisant au change- tion Pour La Lutte Contre Les Grandes Endemies ment de politiques de nutrition.” HNP Discussion (OCCGE) 1960–1998.” Sciences Sociales et Hu- Paper Series, World Bank, Washington, DC. maines, vol. 008: No. 1–2007. Evolution of Nutrition Policy in Senegal 55 Ndiaye, B. 2007. Evolution of Public Nutrition Policies USAID (United States Agency for International De- in Senegal.” Paper prepared for the World Bank velopment), HKI (Helen Keller International), JSI workshop, “Carrots and Sticks: Political Econo- (John Snow International), and CORE Group. my of Nutrition Reforms,” Washington, DC, May 2011. Understanding the Essential Nutrition Ac- 2007. tions (ENA) Framework. Washington, DC: USAID. Partnership for Maternal, Newborn and Child Health. World Bank. 1982. Staff Appraisal Report (SAR): Sen- 2006. Opportunities for Africa’s Newborns: Prac- egal Rural Health Project. Washington, DC: World tical Data, Policy and Programmatic Support for Bank. Newborn Care in Africa. Geneva, Switzerland: World Health Organization. ——— . 1995. Staff Appraisal Report (SAR): Republic of Senegal Community Nutrition Project. Washing- Pelletier, D.L., E.A. Frongillo, D.G. Schroeder, and ton, DC: World Bank. J.P. Habicht. 1994. “A Methodology for Estimating the Contribution of Malnutrition to Child Mortality ——— . 2006. Repositioning Nutrition as Central to in Developing Countries.” Journal of Nutrition 124 Development: A Strategy for Large Scale Action. (10 Suppl.): 2106S–2122S. Washington, DC: World Bank. Republic of Senegal and USAID. 1968. “Proceedings ——— . 2007. Implementation Completion and Results of the West African Conference on Nutrition and Report (ICR): Republic of Senegal in Support of Child Feeding,” Dakar, Senegal, March 25–29. the First Phase Nutrition Enhancement Program. Washington, DC: World Bank. Sall, Macky, and J. Sylla. 2005. “African Prime Min- isters Take Lead in Child Survival.” Lancet 366 ——— . 2010. Scaling Up Nutrition: What Will it Cost? (9502): 1988–89. Washington, DC: World Bank. Sommer, A., I. Tarwotjo, E. Djunaedi, K.P. West, Jr., ——— . 2013. Scaling Up Nutrition: A Framework for A.A. Loeden, R. Tilden, and L. Mele. 1986. “Impact Action. Washington DC: World Bank. of Vitamin A Supplementation on Childhood Mor- tality.” Lancet 327 (8491): 1169–73. WHO Multicentre Growth Reference Study Group. 2006. WHO Child Growth Standards: Length/ UNESCO (United Nations Educational, Scientific Height-for-Age, Weight-for-Age, Weight-for- and Cultural Organization). 1964. Planning for Length, Weight-for-Height and Body Mass Balanced Social and Economic Development in Index-for-Age: Methods and Development. Gene- Senegal. New York: UNESCO. va: World Health Organization. UNICEF (United Nations Children’s Fund), WHO WHO (World Health Organization) and UNICEF. (World Health Organization) and World Bank. 2003. Global Strategy for Infant and Young Child 2016. Joint Child Malnutrition Estimates. New Feeding. Geneva, Switzerland: World Health York: UNICEF. Organization. USAID (United States Agency for International Devel- opment). 1980. An Analysis of Nutrition in Senegal. Washington, DC: USAID. 56 Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal 1818 H Street, NW Washington, DC 20433 Funding for the report was provided by the World Bank and the Japanese Trust Fund for Nutrition. The task force providing oversight of the series was composed of members of the following organizations: