Multisectoral Policy Research Articles

Presence of counterfeit miedicines in Peru 2015-2019: socioeconomic and public health consequences

Objective. To determine the amount of counterfeit drugs admitted to the National Center for Quality Control of the National Institute of Health during the period 2015-2019 and the socioeconomic and public health consequences in our society. Methods. The analysis of the information collected corresponds to counterfeit medicines. This information was processed in a structured spreadsheet with the necessary parameters. Results. Counterfeit medicines in relation to the total medicines analyzed were: 5.7; 7.2; 4.9; 17.0 and 13.3% in 2015, 2016, 2017, 2018 and 2019 respectively. Of 547 counterfeit medicines, according to the ATC Classification, the following therapeutic subgroups stand out: anti-inflammatory and antirheumatic products (22.1%) and antibacterials for systemic use (16.5%). The predominant form of counterfeiting was medicines without an active ingredient (38.6%), followed by those with the correct dose of the active ingredient but from a manufacturer other than the one declared (36.9%). The predominantly counterfeit dosage forms were tablets (69.7%), injectables (8.2%), and capsules (6.8%). 43.7% of counterfeit medicines were of unknown origin. Conclusions. The presence of 8.5% of counterfeit medicines in our country is a problem that not only affects public health, but also causes considerable economic losses, US$177 million per year, and unemployment, 8,791 jobs per year. Metropolitan Lima with 71.7%, continues to be the main focus of the commercialization of counterfeit medicines; whose existence not only occurs in informal markets, but prevails in formal markets. The contribution of this study seeks to be able to develop multisectoral policies that allow stopping the commercialization of these products that represent a scourge in our country.

Bioenergy versus Soil Improvement: Policy Coherence and Implementation Gaps in Crop Residue-Based Bioenergy Development in China

Promoting crop residue-based bioenergy (CRB) is a strategy for mitigating climate change and ensuring water-energy-food security. Although China has abundant crop residues, CRB is not well developed, and several policy targets are not being reached. These implementation gaps need critical examination as CRB development mainly relies on policy support. This examination provides a framework to assess the feasibility of this policy that covers several cross-cutting issues. By reviewing national policies, this paper analyzes the horizontal coherence of multisectoral CRB policies during the last two decades. Based on 55 semi-structured interviews, conducted with stakeholders, civil servants and experts, we analyzed the vertical coherence among policy implementation to further explore the causes of the limited success of CRB policies. The priority given to the cultivation and livestock sectors (particularly for soil improvement) in crop residue utilization policies and the development of energy policy targets resulted in horizontal policy incoherence. Furthermore, financial limitations were shown to be the most significant obstacle to CRB policy implementation. Successful CRB policy implementation requires a debate about the crop residue utilization for either energy or fertilizer to determine the more sustainable application. Appropriate incentives and increased technological quality of bioenergy projects are also recommended.

The role of causal ideas in the governance of commercial determinants of health. A qualitative study of tobacco control in the pacific

The consumption of tobacco, alcohol and ultra-processed foods and beverages drives the global noncommunicable disease (NCD) crisis in Pacific small island developing states (PSIDS). Addressing the commercial determinants of health (CDoH) requires policy coherence across government sectors; however, entrenched neoliberal ideologies that exhort self-regulation of markets and market actors impede such efforts. This paper aims to explore the roles ideas play in governing CDoH, through the analysis of causal ideas in multisectoral tobacco governance in Fiji and Vanuatu. An explorative, qualitative case study design was applied. Data collection relied primarily on in-depth interviews, of which 70 were conducted between 2018 and 2019. Data analysis was guided by a theory-informed analytical framework. Two causal ideas influence multisectoral tobacco governance in Fiji and Vanuatu. According to the idea of individual responsibility, high smoking prevalence is the consequence of individuals’ unhealthy lifestyle choices; it nominates the Ministry of Health as the responsible actor to solve this issue by providing health education. In contrast, the idea of CDoH argues that harmful commodity industries drive the NCD epidemic, and the sectors that regulate these private actors should be kept in closer check to ensure that their policies are aligned with the objectives of public health. In Fiji and Vanuatu, the non-health government agencies are effectively excused from implementing multisectoral tobacco policies because the dominant idea of individual responsibility relieves them of any responsibility. The wider adoption of the idea of CDoH is needed in PSIDS to tackle the NCD crisis.

How can policymakers incorporate uncertainty (as modelled through foresight) into policy evaluation?

Abstract Background Using a robust policy evaluation framework is critical to inform policymakers about the relevance of a policy in a structured way, clarifying its implications and providing arguments and criteria to compare competing options and decide which policy should be prioritised. In the current context of complex societal, environmental and public health challenges, decision-makers demand tools that allow a comparative assessment of the effectiveness of multisectoral policies and their comparison under different scenarios. Methods This presentation will detail a socio-technical “desirability-doability” framework (2xD). In 2xD, an additive value model is constructed to measure the desirability of public policies, and their doability is appraised under two contrasted scenarios. For these purposes, the MACBETH approach is used in developing the three group modelling phases of 2xD: (I) Structuring facilitated workshops, (II) Evaluation decision conference, and (III) Desirability-doability decision conference. Tailor-made interactive protocols or questioning procedures are used to elicit group judgements, based on which objective-specific value scores are assigned to the policies, and the objectives are weighted (in II). Finally, we elicit doability scores for the policies under each scenario (in III). Results We present how the 2xD framework was applied in Lisbon's urban health policymaking setting and discuss case insights regarding the role of scenario analysis in the appraisal and selection of policies. Conclusions The 2xD framework advances knowledge on how to assist policymakers in evaluating and selecting policies and contributes to the literature on overall policy formulation and evaluation. Specifically, the framework enabled a group of policymakers to balance (multicriteria) desirability versus doability of policies under the light of two contrasting scenarios, therefore incorporating uncertainty in their decision-making process.

Multi-Level Correlates of the Nutritional Status of Nigerian Women of Reproductive Age.

Poor nutrition compromises the capacity of women to perform their vital roles as mothers and productive workers in their families, communities and society. Using a conceptual framework developed by the United Nations Children's Fund, this study determines individual-, household- and community-level factors associated with the nutritional status of Nigerian women of reproductive age. A secondary analysis of pooled data from the Nigeria Demographic and Health Survey (NDHS) for 2003, 2008, 2013 and 2018 was conducted involving 82,734 non-pregnant women aged 15-49years. Multinomial logistic regression was used to determine predictors of nutritional status. Study results show that a significant proportion of the women had poor nutritional status; the prevalence of underweight, overweight and obesity were 12.1%, 16.8% and 7.2% respectively. Statistically significant factors associated with poor nutritional status were found at all three levels, highlighting the need for effective multidimensional, multisectoral policy interventions to address the double burden of malnutrition among women in Nigeria.

Strengthening implementation of diet-related non-communicable disease prevention strategies in Fiji: a qualitative policy landscape analysis

BackgroundNoncommunicable diseases (NCDs) are the leading cause of death globally, and the World Health Organization (WHO) has recommended a comprehensive policy package for their prevention and control. However, implementing robust, best-practice policies remains a global challenge. In Fiji, despite political commitment to reducing the health and economic costs of NCDs, prevalence of diabetes and cardiovascular disease remain the highest in the region. The objective of this study was to describe the political and policy context for preventing diet-related NCDs in Fiji and policy alignment with WHO recommendations and global targets. We used a case study methodology and conducted (1) semi-structured key informant interviews with stakeholders relevant to diet-related NCD policy in Fiji (n = 18), (2) documentary policy analysis using policy theoretical frameworks (n = 11), (3) documentary stakeholder analysis (n = 7), and (4) corporate political activity analysis of Fiji’s food and beverage industry (n = 12). Data were sourced through publicly available documents on government websites, internet searches and via in-country colleagues and analysed thematically.ResultsOpportunities to strengthen and scale-up NCD policies in Fiji in line with WHO recommendations included (1) strengthening multisectoral policy engagement, (2) ensuring a nutrition- and health-in-all policy approach, (3) using a whole-of-society approach to tighten political action across sectors, and (4) identifying and countering food industry influence.ConclusionDiet-related NCD policy in Fiji will be strengthened with clearly defined partner roles, responsibilities and accountability mechanisms, clear budget allocation and strong institutional governance structures that can support and counter industry influence. Such initiatives will be needed to reduce the NCD burden in Fiji.

Impact of sustained health policy and population-level interventions on reducing the prevalence of obesity in the Caribbean region: A qualitative study from The Bahamas.

BackgroundThe 2020 Global Nutrition Report highlights that despite improvements in select nutrition indicators, progress is too slow to meet the 2025 Global Nutrition Targets. While the Latin America and the Caribbean (LAC) region has achieved the greatest global reduction in undernutrition (stunting, underweight, and wasting) in the past decade, it also has the highest prevalence of people with overweight worldwide. Since the early 2000s, the region has mounted increasingly comprehensive and multi-sectoral policy interventions to address nutritional health outcomes. The Bahamas is one such LAC country that has used consistent policy responses to address evolving nutritional challenges in its population. After addressing the initial problems of undernutrition in the 1970s and 80s, however, overconsumption of unhealthy foods has led to a rising prevalence of obesity which The Bahamas has grappled with since the early 2000s.ObjectiveThis study develops a timeline of obesity-related health policy responses and explores the macrosocial factors and conditions which facilitated or constrained public health policy responses to obesity in The Bahamas over a 20-year period.MethodsThis multi-method case study was conducted between 2019 and 2021. A document review of health policies was combined with secondary analysis of a range of other documents and semi-structured interviews with key actors (policymakers, health workers, scholars, and members of the public). Data sources for secondary data analysis included policy documents, national survey data on obesity, national and regional newspaper websites, and the Digital Library of the Caribbean database. An adapted framework approach was used for the analysis of semi-structured interviews.ResultsBetween 2000 and 2019, a series of national policies and community-level interventions were enacted to address the prevalence of obesity. Building on previous interventions, obtaining multi-sectoral collaboration, and community buy-in for policy action contributed to reducing obesity prevalence from 49.2 to 43.7% between 2012 and 2019. There are, however, constraining factors, such as political and multi-sectoral challenges and gaps in legislative mandates and financing.ConclusionSustained multilevel interventions are effective in addressing the prevalence of obesity. To maintain progress, there is a need to implement gender-specific responses while ensuring accessibility, availability, and affordability of nutritious food for all.

S02-5 Physical inactivity in nine Eastern European and Central Asian countries: results from the WHO STEPwise approach to NCD risk factor surveillance

BackgroundPhysical inactivity is a major risk factor for noncommunicable diseases. This paper explores patterns of physical inactivity in Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Moldova, Tajikistan, Türkiye and Uzbekistan.MethodsNationally-representative data were collected through the WHO STEPwise survey of noncommunicable disease risk factors, which utilizes the Global Physical Activity Questionnaire (GPAQ) to estimate population physical inactivity.ResultsThe prevalence of physical inactivity varied across the region, from 11.4 to 44.7%, and was higher among women than men in all countries except for Armenia, Belarus and Moldova. In most countries, the highest proportion of physical activity levels were registered during work time and appeared to vary according to the countries’ level of development. For both sexes and across all populations, time spent on leisure or recreational physical activity was low.ConclusionsThese results have important implications for policy, including actions to promote active travel and leisure-time physical activity as countries develop economically. Investments in workplace physical activity programmes and infrastructure are needed as populations transition to sedentary from more physically active occupations. The results reiterate the need for multisectoral policies, programmes and interventions to promote physical activity tailored to the local context.

Balancing national economic policy outcomes for sustainable development

The 2030 Sustainable Development Goals (SDGs) aim at jointly improving economic, social, and environmental outcomes for human prosperity and planetary health. However, designing national economic policies that support advancement across multiple Sustainable Development Goals is hindered by the complexities of multi-sector economies and often conflicting policies. To address this, we introduce a national-scale design framework that can enable policymakers to sift through complex, non-linear, multi-sector policy spaces to identify efficient policy portfolios that balance economic, social, and environmental goals. The framework combines economy-wide sustainability simulation and artificial intelligence-driven multiobjective, multi-SDG policy search and machine learning. The framework can support multi-sector, multi-actor policy deliberation to screen efficient policy portfolios. We demonstrate the utility of the framework for a case study of Egypt by identifying policy portfolios that achieve efficient mixes of poverty and inequality reduction, economic growth, and climate change mitigation. The results show that integrated policy strategies can help achieve sustainable development while balancing adverse economic, social, and political impacts of reforms.

Thailand Achievement of SDG Indicator 4.2.1 on Early Child Development: An Analysis of the 2019 Multiple Indicator Cluster Survey.

The early years of a child’s life are the foundation for their future capability development. Poor health, hunger, poverty, low parental education, lack of parental interaction, high screen time, and poor housing environment hamper their development. There is little evidence of a link between early child development (ECD) and sociodemographic factors in Thailand. In response to monitoring the achievement of SDG target 4.2.1 (the proportion of young children who are developmentally on track in health, learning and psychosocial well-being) as required by all UN Member States, this study analyses the prevalence of appropriate levels of ECD and its correlates of Thai children aged 3 to 4 years. A cross-sectional study of the 6th Multiple Indicator Cluster Survey (MICS) data in 2019 conducted by the National Statistical Office was employed. Face-to-face interviews with mothers and/or legal guardians were conducted. A total of 5787 children aged 3 to 4 were enrolled in this study. The majority of participants, approximately 92.3%, had achieved an appropriate level of ECD index, defined as children who were developmentally on track in at least three out of these four domains: cognitive, physical, social, and learning. Multivariate logistic regression showed that girls had a higher appropriate development index than boys (Adjusted Odds Ratio [AOR] = 1.56, 95% Confidence Interval [95% CI] 1.28–1.90; children living in the 5th wealth quintile had a higher appropriate index than those in a less well-off family the first wealth quintile (AOR = 2.92, 95% CI: 1.86–4.58. Univariate logistic regression showed children living with parents achieving post-secondary education had a significantly greater appropriate index than children living with parents completing secondary education or below (Crude OR = 1.95, 95% CI 1.47–2.58); children who had appropriate parental interactions of more than four out of six interactions, had a significantly higher chance of having an appropriate index than less than four interactions (Crude OR = 1.52, 95% CI 1.14–2.04). Multi-sectoral policies to support child development in low socio-economic households should be strengthened. In addition, family and community should promote parental interactions through reading and playing with young children. Future studies which directly measure ECD in conjunction with regular monitoring through MICS are recommended.

The role of context in identifying linkages between SDG 2 (food) and SDG 6 (water)

The Sustainable Development Goals (SDGs) of the United Nation’s Agenda 2030 are formulated to promote the development of integrated, multisectoral policies that explicitly consider linkages across SDGs. Although multiple recent studies have tried to identify linkages across SDGs, the role of contextual factors in identifying SDG linkages is neither well described nor understood. For the case of SDG 2 and SDG 6, this study aims to (i) identify linkages—at country and SDG target level—through the application of various quantitative and qualitative identification methods, and (ii) explore contextual factors to explain the differences across identified linkages. Hereto, we first conducted a text analysis of 195 Voluntary National Reviews (VNRs) reported by 159 countries from 2016 to 2020. Next, we synthesized linkages reported by previous qualitative studies and conducted a quantitative (correlation) analysis on the UN’s SDG database. Last, we compared identified linkages across methods, paying special attention to the role of context. From the text analysis, we identified 221 country-specific linkages between 25 SDG target pairs and observed that countries increasingly report SDG linkages in their VNRs over time. Comparing text analysis, existing qualitative studies, and our quantitative correlation analysis, we found substantial differences between the number and nature of linkages identified. These differences can be explained in part by methodological considerations, but to a significant extent also by contextual factors, such as project design, technology application, phase of interventions, and project scale. We conclude by discussing the strengths and limitations of the methods involved, and suggestions for future studies.

Beyond the garden: The complexity of "global and individual living" at the heart of the international commitment towards a healthy, more resilient and fairer society.

The right to fully enjoy the highest possible state of health is certainly nothing new in the agenda of the world's governments, and yet today it becomes a top priority not just in the restructuring of the health care system, but also in the promotion of multi-sector policies aimed at fostering and safeguarding the potential of every individual to achieve what could be defined, in general terms, as "common good". The current paper aimed at singling out the most useful strategies to promoting and achieving a healthy, more resilient and fairer society. Starting from principles 1 and 14 of the Declaration of Rome, the aim was to analyse and develop the concepts of resilience and health, questioning their possible future variations against the background of the current health emergency and the increasingly radical widespread use of new technologies as universally-applied and cross-sectional tools for human progress. The "health for all" objective can only be achieved if we act on three key aspects: 1. Adding life to years; 2. Adding life to life; 3. Adding years to life. Each individual should raise their health awareness as a key resource to leading a fulfilling existence and to developing the required qualities to fully tap into health possibilities - whether integral or residual - to tackle life.

Meeting U.S. greenhouse gas emissions goals with the international air pollution provision of the clean air act

We explore economic, distributional and health consequences of U.S. greenhouse gas emissions objectives that could be achieved using Section 115 of the Clean Air Act (international air pollution), which has only recently received detailed legal analysis as a potential U.S. climate policy tool. Under it a national emissions target could be allocated among the states. This illustrative analysis considers 45% and 50% reductions of energy and industry-related CO2 emissions by 2030, below 2005 levels, via a model rule. Different approaches (based on legal precedent) for the interstate allocation are considered, along with alternative rates of technology improvement. The detail needed to analyze this approach is provided by MIT’s U.S. Regional Energy Policy model (30 individual states and multi-state regions), with its electricity sector replaced by the U.S. National Renewable Energy Laboratory’s Renewable Energy Development System (ReEDS). Air quality benefits are estimated using modeling tools developed by academic researchers and the U.S. Environmental Protection Agency. Three-quarters of emissions reductions in 2030 come in the electric sector, while reductions elsewhere illustrate the efficiency advantage of a multi-sector policy. With all states participating in allowance trading, the resulting national emissions price is lower than in older assessments. The difference is due to lower growth expectations, recent state policies, falling costs of low carbon technologies, and an improved representation of electric system flexibility by the ReEDS model. Even ignoring climate and air quality benefits, economic welfare grows at near the baseline rate for all regions regardless of the interstate allocation approach. When states distribute allowance revenue to residents on an equal per-capita basis, the policy is welfare improving to the lowest income quintile in all regions. Aggregation of control costs, the mortality effects of reduced particulates, and the value of avoided climate damages yields positive national net benefits in all cases.

Improving policy environments for infants and young children: global status of multisectoral national policies for early childhood development

ABSTRACT Multisectoral national policies for early childhood development (ECD) have been developed since 1979, yet until now the number of countries adopting them has not been systematically documented. Numerous global declarations, including Education for All and the Sustainable Development Goals (SDGs), have supported ECD policy planning. Selection and search criteria were established and applied to identify and classify multisectoral ECD policy documents. A descriptive study was conducted to assess historical trends in policy adoption, regional coverage, income levels, governance categories, and crisis countries. Policies were first developed in Colombia, and later in Namibia, South Africa, Mauritius and Maldives. By December 2019, 76 countries (39% of 197 countries worldwide) and one territory had adopted 125 multisectoral ECD policy instruments. Of them, 51% were policies; 37% strategies and/or action plans; 11% laws; and 7% regulatory documents. By 2010, 43 countries had adopted an ECD policy instrument, peaking in 2011 when 14 countries adopted policies. From 2012 to 2019, 29 countries adopted a policy. South Asia (88%), Latin America and the Caribbean (65%), and Sub-Saharan Africa (58%) lead policy development. Policies have been adopted by 53% of low-income countries and 55% of lower middle-income countries. Fewer upper middle-income countries (38%) and high-income countries (14%) have adopted an ECD policy. Previous research found that countries using participatory policy planning processes resulted in well-implemented ECD policies. The presence of a multisectoral ECD policy prepared in a participatory manner helps establish a strong enabling environment for expanding and improving ECD services. To attain SDG 4.2, additional lower- and middle-income countries, countries with emergencies, and authoritarian regimes should be prioritized for support. Finally, we recommend an indicator be established to identify the number of countries that have adopted ECD policies to help measure SDG 4.2.

Situating Health Within the 2030 Agenda-A Practical Application of the Sustainable Development Goals Synergies Approach.

Background: The Sustainable Development Goals (SDGs) are integrated, indivisible and interdependent and interact and affect each other directly and indirectly. However, the 2030 Agenda does not attempt to identify or characterise these interactions. Evidence: The SDG Synergies approach was developed to enable the investigation of the strength and nature of interactions between SDGs based on the perception of a multistakeholder group. Two examples are given to concretely demonstrate how this approach overcomes present challenges and can be applied to situate health within the 2030 Agenda. Policy Options and Recommendations: There are clear benefits to situate desired health policy outcomes within the 2030 Agenda, and the SDG Synergies approach can be used as lever for including health aspects in traditional non-health sectors. Although focusing on specific health policies cannot be substituted with multisectoral policies alone, utilizing tools and methods such as the SDG Synergies approach can help policy makers put health at the centre of the SDGs. Conclusion: SDG Synergies is an impactful approach for policy makers to gain a systemic understanding of how broader sustainable development shape the health and well-being of people and vice versa.

Biopsychosocial factors influencing the occurrence and recurrence of preterm singleton births among Australian women: A prospective cohort study

IntroductionIn Australia, 8.6% of all births are premature, and this figure has relativelyincreased by 10% in the past decade. A range of biological, psychological, and socialfactors have previously been identified as predictors of preterm birth using cross sectionaldata; however, this lacks ascertainment of a cause-and-effect relationship.This study harnessed the power of longitudinal cohort data by investigating pretermbirth among women prospectively followed for 19 years using a comprehensiveframework that examines biological, psychological, and social factors concurrently. MethodsData from 5,292 women (11,256 newborns) who reported singleton birthsbetween 1996 and 2015 in the Australian Longitudinal Study on Women’s Health wereincluded. ResultsThe prevalence of preterm birth was 8.5% for first-births and 5.9% for allbirths.The recurrent preterm birth rate was 9.5% . Risk factors for first preterm birthswere chronic hypertension (OR 2.34; 95% CI: 1.67-3.27), gestational hypertension (OR2.87; 95% CI: 2.22-3.72), gestational diabetes (OR 1.66; 95% CI: 1.14-2.41),menarche before 12 years (OR 1.36; 95% CI: 1.02-1.82) and history of miscarriage(OR 1.35; 95% CI: 1.01-1.79). Risk factors for all preterm births were a history ofpreterm birth (OR 2.33; 95% CI: 1.46-3.70), menarche before 12 years (OR 1.33; 95%CI: 1.00-1.77), not being partnered (OR 1.31; 95% CI: 1.02-1.69), chronic hypertension(OR 2.02; 95% CI: 1.45-2.82), gestational hypertension (OR 3.22; 95% CI: 2.43-4.25),gestational diabetes (OR 1.67; 95% CI: 1.16-2.41), and asthma (OR 1.40; 95% CI:1.14-1.72). Premature birth was less likely for second or later births (OR 0.44; 95% CI:0.36-0.55) compared to first births. Premature birth was also less likely for women whocompleted a university degree compared to women with a high school certificate (OR0.73; 95% CI: 0.57-0.94). ConclusionFurther development of multi-sectoral policies for chronic diseaseprevention and reducing social inequalities is required to prevent preterm birth inAustralia.

Nutrition-sensitive education and social protection policies have implications for food-based dietary guidelines for Ghana

Ghana continues to address persistent malnutrition through political action and programme development. Government-led efforts have included the formulation of multi-sectoral policies and programmes to improve the diet and nutritional status of various at-risk population groups. Globally, an important tool for promoting healthy diets are Food-Based Dietary Guidelines (FDBGs). To achieve and sustain the desired goal of promoting healthy eating habits and lifestyles, FBDGs require, among many factors, supportive national policies and programmes. When coherently incorporated in relevant nutrition-related policies and programmes, FBDGs enhance their impact on shaping and sustaining healthier dietary habits. In this context, it is essential to understand the national policy and programme environment and its potential contribution during the formulation of FBDGs. The present review aimed to identify existing nutrition-related education and social protection policies and programmes in Ghana and their relevance to the development and implementation of FBDGs. Previously conducted scoping reviews, gap analyses, and a benchmarking report of Ghana’s public health nutrition policies were used as information sources to identify relevant policies and programmes. Additionally, websites of relevant government ministries, departments and agencies were searched to retrieve applicable policies or actions that were not included in previous reviews. Nutrition-related education policies that were identified primarily support school health services, whereas social protection policies broadly target social assistance, social welfare, social equity and insurance-based policies and programmes. Specific ways these policies and programmes could support the development and implementation of Ghana’s dietary guidelines include embedding FBDGs in the school nutrition curriculum to motivate healthier food choices by schoolchildren and using FBDGs to plan meals provided as part of the country’s school feeding programme. Regarding social protection, existing instruments such as food transfers, social pensions and conditional cash transfers could be aligned with FBDGs to ensure vulnerable households can access foods and follow recommended guidelines. Although some nutrition actions are incorporated in existing policies and programmes, there are opportunities to improve their nutrition sensitivity. Key words: Ghana, food-based dietary guidelines, nutrition education, social

Translation of policy for reducing undernutrition from national to sub-national levels in Rwanda

Understanding how countries improve children’s nutrition can inform policies and contribute to further improvements. We examined the relationship between improvements in nutrition in Rwanda (1992–2017) and political commitment to- and policy coherence in- nutrition. We reviewed nutrition-relevant Rwandan policies and programs (2000–2018) and conducted 90 semi-structured interviews with national (n = 32), mid-level (n = 38), and community (n = 20) nutrition stakeholders and 40 community-level focus group discussions (FGDs). FGDs and sub-national interviews were conducted in ten purposefully selected districts, five each in which stunting decreased (reduced) and increased or stagnated (non-reduced) between the 2010 and 2014/15 Rwanda Demographic and Health Surveys. Analysis consisted of thematic analysis and the assessment of events, policy developments, and strategies that influenced nutrition in Rwanda, including operationalization of political commitment and policy coherence for nutrition. Political and institutional commitment to nutrition increased in Rwanda as evidenced by the adoption of a multisectoral nutrition policy that was reinforced with national and subnational horizontal coordination platforms. These platforms strengthened multisectoral strategies to address nutrition and supported operational and institutional commitment. The role of mid-level actors in nutrition governance increased as responsibilities for planning, implementing, and monitoring nutrition programs were increasingly delegated to sub-national administrative levels. Variations in policy implementation existed between reduced and non-reduced districts. Despite improvements, challenges remained in coordination, financial commitment, and capacity to address, monitor, and evaluate nutrition. Political commitment to- and policy coherence in- nutrition at the national level are important for improving nutrition, and when reinforced institutionally, can be translated to sub-national levels where implementation occurs.

Changes in Inequality in Use of Maternal Health Care Services: Evidence from Skilled Birth Attendance in Mauritania for the Period 2007-2015.

Skilled birth attendance is critical to reduce infant and maternal mortality. Health development plans and strategies, especially in developing countries, consider equity in access to maternal health care services as a priority. This study aimed to measure and analyze the inequality in the use of skilled birth attendance services in Mauritania. The study identifies the inequality determinants and explores its changes over the period 2007–2015. The concentration curve, concentration index, decomposition of the concentration index, and Oaxaca-type decomposition technique were performed to measure socioeconomically-based inequalities in skilled birth attendance services utilization, and to identify the contribution of different determinants to such inequality as well as the changes in inequality overtime using data from Mauritania Multiple Indicator Cluster Surveys (MICS) 2007 and 2015. The concentration index for skilled birth attendance services use dropped from 0.6324 (p < 0.001) in 2007 to 0.5852 (p < 0.001) in 2015. Prenatal care, household wealth level, and rural−urban residence contributed most to socioeconomic inequality. The concentration index decomposition and the Oaxaca-type decomposition revealed that changes in prenatal care and rural−urban residence contributed positively to lower inequality, but household economic status had an opposite contribution. Clearly, the pro-rich inequality in skilled birth attendance is high in Mauritania, despite a slight decrease during the study period. Policy actions on eliminating geographical and socioeconomic inequalities should target increased access to skilled birth attendance. Multisectoral policy action is needed to improve social determinants of health and to remove health system bottlenecks. This will include the socioeconomic empowerment of women and girls, while enhancing the availability and affordability of reproductive and maternal health commodities. This policy action can be achieved through improving the availability of obstetric service providers in rural areas; ensuring better distribution and quality of health infrastructure, particularly health posts and health centers; and, ensuring user fees removal for equitable, efficient, and sustainable financial protection in line with the universal health coverage objectives.

Socioeconomic Effects of COVID-19 in Mexico: A Multisectoral Approach and Policy Options

The health crisis caused by the spread of COVID-19 has caused a profound social and economic disruption in Mexico. Our purpose in this paper is to contribute to the knowledge about the economic impact of the pandemic in Mexico and to evaluate social policy options to mitigate its effects. We do so based on a multisectoral-multiplier model and the most recent Social Accounting Matrix for Mexico, with which we estimate the direct and indirect impacts of COVID-19 as well the likely effects of two alternatives for mitigating them: an unconditional cash transfer scheme for households living in poverty, and the establishment of an unemployment insurance program for workers who have lost their jobs during the pandemic. We find that the first alternative alleviates more value added and loss of income, and thus has a greater effect in reducing inequality and the incidence of poverty.