Planning Capacity, Determinants, and Challenges of Integrating Multisectoral Nutrition into Communal Development Plans in Burkina Faso

Introduction Translating national policies into concretes actions at sub-national level is a prerequisite to scaling up interventions and ensuring an impact on the nutritional status of populations. The objective of this study was to analyze the overall process of local planning in Burkina Faso to identify factors that positively and negatively influence the process of integrating nutrition into communal development plans (CDP). Methods This was a qualitative study conducted through: (1) an analytical review of communal development plans (CDP) in ten municipalities from two regions, (2) individual interviews and focus groups with key informants and (3) a national triangulation workshop. The assessment was informed by a theoretical framework designed to determine the degree to which nutrition was integrated in the CDP, stakeholders’ capacities and resources, as well as the governance and the quality of the overall local planning process. The data were processed (transcription, coding, synthesizing) by themes using a deductive approach. Results The degree of nutrition integration in the CDP varied from one municipality to another. Despite the high prevalence of malnutrition in all municipalities, 60% of the CDP did not have a good nutrition coverage related to integration of nutrition into plans and had not planned multisectoral interventions to combat malnutrition. The main obstacles to this integration included ignorance of malnutrition by local elected officials, low planning capacity of stakeholders and scarcity of resources, insufficient participative and inclusive local planning approaches, a lack of guidelines about nutrition integration, a preference among officials to invest in physical infrastructures and obstacles related to governance. The key factors facilitating integration of nutrition included the internationalization of the local planning process, the presence of nutrition partners in the municipalities and the existence of financial prospects. Conclusion Nutrition integration in the CDP is a major challenge for Burkina Faso. However, revising or developing CDP is an opportunity to improve nutrition.

Abstract: Introduction Translating national policies into concretes actions at sub-national level is a prerequisite to scaling up interventions and ensuring an impact on the nutritional status of populations. The objective of this study was to analyze the overall process of local planning in Burkina Faso to identify factors that positively and negatively influence the process of integrating nutrition into communal development plans (CDP). Methods This was a qualitative study conducted through: (1) an analytical review of communal development plans (CDP) in ten municipalities from two regions, (2) individual interviews and focus groups with key informants and (3) a national triangulation workshop. The assessment was informed by a theoretical framework designed to determine the degree to which nutrition was integrated in the CDP, stakeholders' capacities and resources, as well as the governance and the quality of the overall local planning process. The data were processed (transcription, coding, synthesizing) by themes using a deductive approach. Results The degree of nutrition integration in the CDP varied from one municipality to another. Despite the high prevalence of malnutrition in all municipalities, 60% of the CDP did not have a good nutrition coverage related to integration of nutrition into plans and had not planned multisectoral interventions to combat malnutrition. The main obstacles to this integration included ignorance of malnutrition by local elected officials, low planning capacity of stakeholders and scarcity of resources, insufficient participative and inclusive local planning approaches, a lack of guidelines about nutrition integration, a preference among officials to invest in physical infrastructures and obstacles related to governance. The key factors facilitating integration of nutrition included the internationalization of the local planning process, the presence of nutrition partners in the municipalities and the existence of financial prospects. Conclusion Nutrition integration in the CDP is a major challenge for Burkina Faso. However, revising or developing CDP is an opportunity to improve nutrition.

Introduction
In Burkina Faso, the situation of malnutrition is very worrying. Nearly one in three children under five suffer from stunting and 8.6% of global acute malnutrition prevalence [1]. The current trend may hinder the achievement of Sustainable Development Goals (SDGs) [1].
Malnutrition is a complex issue that is caused by many determinates and depends on multiple factors. As a result, multisectoral planning is indispensable tool to enable different sectors and actors to better modify their plans for a common goal [2][3][4].
Like many other countries that have joined the "Scaling Up Nutrition" movement, Burkina Faso revised the National Nutrition Policy (NNP) and developed a Multisectoral Nutrition Strategic Plan (MNSP) [5,6]. However, some authors are unanimous in emphasizing that the translation of national policies and strategies into effective decentralized actions is a prerequisite for improving the coverage of interventions and ensuring a nutritional impact [7][8][9]. Communal Development Plans (CDP) provide a framework for better integrating multisectoral approaches to nutrition, increasing coverage of interventions and reducing undernutrition [8,[10][11][12]. The decentralization theory argues that services quality can be improved with the engagement of local citizens, accountability, improved local capacities and the elimination of delays due to decision-making [13].
In Burkina Faso, communes or municipalities are responsible for developing their own communal development plans. Thus, the first CDP initiatives were developed for some regions of Burkina Faso in 2013 in accordance with directives of the central level [13]. In 2015, an evaluation study showed that communal plans did not take account of nutrition sufficiently, except in municipalities supported by an NGO. Since then, the question of how to better integrate nutrition into the communal development plans (CDP) to improve the coverage of multisectoral nutrition interventions and have the biggest impact on nutrition has been asked.
To address this question and in absence of a nutrition integration strategy in the CDP, we proposed to analyze the overall process of local planning to identify the drivers and challenges of the process of nutrition integration in the communal development plans.

Methods
This is a qualitative study conducted in Ouagadougou, Burkina Faso in 2017.
An analytical review of communal development plans (CDP), individual and group interviews and a national triangulation workshop were conducted with the following steps: The analytical review of communal development plans (CDP) was the first step and conducted in ten (10) municipalities from two regions (Sahel and East regions), where the prevalence of stunting was the highest compared to the rest of the country. The review consisted of evaluating the degree of integration of nutrition in these plans. The municipalities were chosen randomly from a nominative list of municipalities in these two regions. Five (5) municipalities were selected in the Sahel region (Gayeri, Kantchari, Tibga, Thion and Mani) out of a total of 27 and five (5) municipalities were selected in the East out of 27as well (Gorom-Gorom, Tongomayel, Bani, Titabe and Sebba). The integration evaluation used an approach developed by REACH (Renewed Efforts Against Child Hunger and undernutrition). It is based on two streams of standardized criteria that verify the coverage of nutrition in the CDP through scores, with a weighting of 50% for each stream. The first stream analyzes whether the plan recognizes malnutrition as a problem and the existence of goals or nutrition indicators. This was determined by answering two questions: (i) is malnutrition recognized as a problem by the plan? and (ii) is there any goals or indicators related to nutrition? For each question if the answer is « yes », the coding was 25% and if the answer is NO, the coding was 0%. The real score for this stream was the add up of the two indicators. The second stream assesses the proportion of nutrition interventions within the plan compared to the priority and relevant interventions listed in it. This was determined by answering two questions: (i) what is the number of nutrition interventions included in the plan on the total number of nutrition interventions? and (ii) what is the number of nutrition interventions included in the plan on the total number of relevant nutrition interventions related to the CDP area? The intervention list selected in the common results framework was used as a reading grid. The combination of the two stream scores provides an overall mark presented as « Harvey balls » in order to estimate the level of nutrition integration in each CDP ( Figure 1).
The second step was the Semi-Structured Individual Interviews and Focus Group, which were conducted in October 2017 with 45 key stakeholders selected on the basis of their involvement in the local planning process. These stakeholders included: a) Fifteen (15) people from the territorial and decentralization administration at the central level, ministries (Health, education, food security, WASH, social protection, economy and finances) and partners; b) Twelve (12) stakeholders from the regional level in the East and the Sahel from the sectors mentioned above (Sahel and East regions); c) And eighteen (18) stakeholders from three municipalities at the decentralized level (Fada N'Gourma in the East, Falangoutou in the Sahel, and Houndé in the Hauts-Bassins), that have already proceeded to the revision of their CDP. These stakeholders belonged to municipal council and technical departments (health district, education, water and sanitation, food security and environment). A focus group was conducted with eight (8) technical partners supporting the local planning process and the integration of nutrition into CDP.
The questions asked in the interviews and the topics of the focus groups focused on: the determinants of integrating nutrition into CDP in terms of (i) facilitating factors for integrating nutrition into local planning and (ii) barriers to nutrition integration and (iii) challenges and opportunities to improve nutrition integration in CDP.
Third, the national triangulation workshop was organized at the central level with a total of 39 key stakeholders who are involved in the local planning process and from the above listed sectors, municipalities and partners. This workshop allowed to discuss and consensually identify the main facilitating factors and the challenges to integration as well as opportunities to strengthen the process.
Data analysis techniques. Data from individual interviews, focus group and the national triangulation workshop were encoded and categorized by theme using the software QDA miner and a deductive approach. An adapted theoretical framework of analysis from similar studies related to the decentralized planning and/or the factors influencing the integration was applied [14][15][16].
Criteria for analyzing the overall local planning process. These are: a) Stakeholders' capacities and resources availability: human resource capacities, local expertise in performing local planning, local capacities on the multisectoral approach in nutrition and financial resources. b) Governance and quality of the overall local planning process: Local stakeholders' leadership, policy diffusion, decentralized coordination, accountability, decentralization, effectiveness of the participatory planning approach, local stakeholders' involvement, internationalization/ outsourcing of the development process. c) Main challenges and opportunities. On the ethical level. Informed consent was sought at the beginning of interviews after explaining the objectives of the study, participation was voluntary, and the individual interviews conducted anonymously. The study obtained approval from the Ethics Committee prior authorization from the Ministry of Health after submission of the protocol. This authorization facilitated the introduction of the interviewers to the interviewees.

Degree of Nutrition Integration in Communal Development Plans
The degree of nutrition consideration varies from one municipality to another (table 1). It was noted in the CDP analyzed that malnutrition is a multisectoral problem with unacceptable prevalence (stunting ranging from 28.8% to 42.9%) and that it exists a relation between nutrition and many other sectors like food security, climate change, trade, animal breeding and vulnerability of children and pregnant women.
Despite this situation, 60% of the CDP don't have a good nutrition coverage and have not planned multisectoral interventions to combat malnutrition. Most interventions focused on food insecurity and environment. One municipality out of five (05) in the Sahel and three (03) out of five in the East region have shown an effort to integrate nutrition into their CDP as well as specific intervention as sensitive interventions. These municipalities were supported by international Non-Governmental Organization (NGO).
It should be noted that the preference of local elected officials is for physical investments or visible structures (such as the construction of schools, boreholes, warehouse, health centers); the substitution by partners to support the implementation of nutrition activities, lack of awareness raising targeting rural population or lack of nutrition education are all factors limiting good coverage of nutritional interventions in the CDP.

Local Planning Process in Burkina Faso
The local planning process is defined by the Ministry of Economy and Planning and through its branches (Regional departments of Economy and Planning) at the regional level. At the communal level, the ad hoc committee consists of municipal councilors, representatives of decentralized technical services (health, education, agriculture, animal breeding, environment, water and sanitation, social action), NGOs and local associations. These ad hoc committees are in charge of coordinating the development of CDPs.

Determinants of Nutrition Integration into Communal Development Plans
Data collected during stakeholder interviews and focus groups and during the national triangulation workshop highlighted the following topics:

Stakeholders' Capacities and Available Resources
The main factors hindering the planning process at the decentralized level are inter alia: the weak capacity of human resource at the collectivities level and/or the lack of expertise of local stakeholders in controlling the local planning process and the multisectoral approach to nutrition. Hence, in 2013, the recruitment of external consultants to support the various municipalities. Some actors from decentralized departments deplored the fact that their contributions to the process were not taken into account by the consultants. The lack of financial resources leads to the prioritization of certain areas in detriment of nutrition. According to one stakeholder, "the essential barrier remains the problem of financial resources, although the problem has been diagnosed, if it lacks resources, its integration will not be possible".

Governance and Quality of the Overall Local
Planning Process The weak diffusion of some national policies and strategies from the national level to the decentralized level, the weak ownership by decentralized and municipal services were underlined by the respondents. Town halls do not have reference documents on nutrition and methodological tools on the integration of nutrition. Insufficient communal dialogue on nutrition during communal council sessions, the inadequate consideration of nutrition issues in advocacy strategies as well as in fund raisings, transparency in financial resources management, the weakness of the monitoring-evaluation (M&E) system and the lack of citizen control over the local governance are all limiting factors. Some aspects related to the decentralization process influence integration. Indeed, in the decentralization context, the transfer of skills and resources such as health and education to local communities is likely to favor the process of nutrition integration in the CDP. Moreover, the misunderstanding of some aspects of this transfer of skills and resources creates frictions between health districts and local communities, which sometimes makes integration difficult. Burkina Faso's socio-political environment tends to favor physical investments as a result of population's urgent social demands and has prioritized security aspects to the detriment of social sectors due to the growing insecurity in the country.
At the communal level, although stakeholders perceive malnutrition as multifactorial, they consider it to be in the health domain only. During community diagnoses, malnutrition never stands out as a priority because of the lack of awareness of its causes and consequences. The negative social perceptions associated with malnutrition as "a disease linked to hunger" often create a sense of embarrassment or shame.
In addition, the quality of the process is affected by the poor application of the participatory approach and the limited involvement of certain resource persons, in this case health workers, agriculture agents, and NGOs partners intervening in nutrition at the local level. The fact that nutrition isn't mentioned among the topics to be covered in the terms of reference used for the development of CDP and the outsourcing of planning process is an obstacle. The existence of multiple guides to take into account emerging topics (education, climate change, gender, health, human rights etc.) for municipalities, often written in heavy language that are difficult to understand by communal councils and the community, has been noted. The multiple guides also seems like they would be confusing for municipalities to understand what should be prioritized at all since they are all in silos.

Main Challenges and Opportunities
The data collected during the national triangulation workshop enabled to identify the main challenges that Burkina Faso has for better planning of nutrition at the decentralized level: (i) The sensitization of the authorities and local elected officials on nutrition issues through a national workshop bringing together the mayors of regions and communes, the association of mayors of Burkina Faso (AMBF), some local elected representatives and nutrition actors.
(ii) The need of a methodological guide as a checklist explaining how to insert multisectoral nutrition into communal plans.
(iii) That nutrition is seen as a priority in the budget allocations of collectivities (iv) The active participation of all stakeholders in the local planning and avoidance of outsourcing of by external consultants who can overfly the very important diagnostic phase and produce the document by "copy-paste" from one municipality to another without taking into account the real needs of communities.
Opportunities for improving the integration of nutrition in CDP exist. After the 2016 municipal elections, the newly installed mayors began the process of developing new CDP in line with the National Economic and Social Development Plan (NESDP). The existence of malnutrition data as the results of the national nutrition survey SMART allowed to nurture the elements of advocacy early in the process. The presence of some NGOs partners intervening in nutrition in the municipalities promotes the inclusion of nutrition the CDP. Technical support from Nutrition Directorate and some partners such as REACH, UNICEF (United Nations Children's Fund) and the European Union (EU), have been assets in starting the process.
The existence of funding opportunities in nutrition is an enabling factor for the development of a methodological guide by sectors contributing to nutrition.
The pilot experiences of internationalization of the CDP development process in three communes (Houndé, Fada N'Gourma and Falagountou) through capacity building of the ad hoc committee members to lead the process themselves with the support of the regional Directorate of studies and planning, was noted as a strong point for improving the process during interviews. Table 2 shows the comparison between initial planning process and the one used in the above three communes. The revision of the mining code in June and the implementing decree formalizing the contribution of the mining sector in local development is a fundraising opportunity. As examples, the above listed communes having reviewed their CDP, received funds from mining companies.

Determining Factors of Nutrition Integration in the Communal Development Plans
This study showed that the level of integrating multisectoral nutrition in CDP is still low despite the high prevalence of stunting and other forms of malnutrition. In addition, this nutrition coverage of CDPs is tributary to some enabling factors and barriers to the integration process.
Among these factors, the study shows that the weak human resource capacity, the lack of local expertise in planning, the ignorance of malnutrition and the lack of financial resources have been obstacles to a better consideration of nutrition in CDP. This situation could be explained by the structural aspect or organizational of the mayors, who are composed of elected and administration workers without neither a planning and M&E department nor social department in charge of health issues or social welfare issues [13]. Moreover, the low financial resources are linked to the low allocation of State budget to the local collectivities and the weak mobilization of endogenous and external resources by municipalities. Ignorance of malnutrition and negative perceptions are compounded by the lack of a capacity building plan for local elected representatives on local planning and nutrition as well as the lack of nutrition education of the population [17][18][19][20].
On the other hand, the presence of some NGOs partners and/or civil society organizations (CSOs) intervening in nutrition in the municipalities has promoted the inclusion of multisectoral nutrition in communal plans through advocacy actions on the basis of pertinent nutrition statistical data, specific and sensitive nutrition interventions that have a proven impact, technical assistance and fundraising [17,[21][22][23].
In terms of governance, the weak dissemination of national policy documents from the central level to the local level does not encourage local ownership of these directives. This weak dissemination can be explained by the fact that some national policies or strategies are recently developed or reviewed, such as the nutrition ones in particular, the national nutrition policy and strategic plan multisectoral nutrition 2017-2020, are not reaching the local level everywhere in the country [15]. This could be due to the dissemination channels used (emailing, regional dissemination workshops organization, etc.), the absence of clear directives for disseminating some documents from the central level to local level and the weak involvement of local stakeholders in the development process of policy documents (i.e. the bottom up approach rarely used). However in the current dynamics at the central level, there is an awareness of the multisectoral aspects in nutrition and a commitment of all key sectors in joint planning with nutritional objectives [6,23]. Global initiatives such as the Scaling Up Nutrition movement (SUN), the REACH initiative and the implementation of SUN networks have fostered this awareness of multisectorality in SUN countries [24].
In addition, the lack of a clear strategy of methodological guidance on the integration of multisectoral nutrition into CDP is an obstacle, as noted in a study in Niger, on the integration of acute malnutrition interventions into the health system [25].
In terms of coordination, the absence of multisectoral platform in nutrition at the communal level, given the multiplicity of stakeholders or its fragmentation , is not conducive to fostering dialogue, awareness, stakeholder commitment and nutrition interventions coordination for more synergy and collaboration [7,[26][27][28].
Moreover, the elected officials' preference for physical investments is due to the fact that they have electoral mandates and seek to be re-elected by highlighting physical achievements, visible under their mandates [13,17]. This situation is also favored by the fact that people place more importance on physical and visible investments than prevention. This would be to the detriment of "invisible" investments in nutrition prevention actions such as malnutrition screening, nutrition education, promotion of optimal practices for Infants and Young Children Feeding.
In the context of decentralization, the transfer of skills and resources from some departments such as health to the collectivities is at the root of some difficult relationships between the health district and the latter. This difficult relationship could be linked to the loss of leadership of certain decentralized services [8,13,16]. A clarification of the management methods of transferred funds, the reinforcement of the local elected representatives' skills, will enable them to fully play their roles.
Furthermore, the weakness of social accountability in the local governance is due among other things, to the lack of a culture of accountability among local elected representatives, the absence of structural mechanisms at the local level, and to the low local capacity to develop mechanisms of control and citizen involvement [29,30].

Challenges of Integrating Nutrition into Communal Development Plans
Beyond governance issues, the quality of the local planning process influences the consideration of real community needs. These results corroborate with those of a study carried out in Vietnam, which shows that the low use of participatory and inclusive approach does not make it possible to identify local realities on the basis of community diagnosis [8]. Moreover, the outsourcing of the CDP development process did not take into account the real needs of the population; this is evidenced by the first experiences of CDP formulation in Burkina Faso done with the help of external firms.
On the other hand, the experiences of internationalization by strengthening local planning capacities to drive the process themselves, have resulted in a content of CDP adapted to the real needs of communities and a better consideration of nutrition [17].
Despite the internationalization, fundraising issues and the quality of CDPs implementing remain challenges of the multisectoral governance in nutrition at the decentralized level [31,32]. The creation of a nutrition budget line in CDP, the systematic insertion of nutrition in social management plans of mining companies, the use of innovative financing, the advocacy to increase State allocations, the development of a resource mobilization plan, the organization of partners' roundtable meetings, are ways to improve nutrition funding at the collectivities level.

Methodological Aspects
Concerning methodological aspects of the study, the use of two main methodological frameworks of analysis, Atun and that of Shiffman and Smith, and their adaptations to the subject and context of this study, allowed to identify and analyze the key facilitating factors and barriers to the process of integrating nutrition into local plans and to result in a more robust framework for interpreting these factors [14,16].
However, this study has limitations but can provide lessons learned to improve the design of similar studies on integrating nutrition in CDP. Firstly, the size of the sample of ten municipalities in two regions for the literature review and three communes for the individual interviews in a country where we have 13 regions and 359 communes, probably doesn't allow to capture all challenges. A participatory observation in the local planning process and an in-depth analysis of social interactions among stakeholders involved the nutrition integration in CDP would allow to better understand the paths of influence of nutrition integration in CDP [33].

Conclusion
This study contributed to improve knowledge of key factors influencing the process of considering nutrition in decentralized planning. Inclusion or ownership of cross-cutting themes in the planning process is sometimes slow. However, strengthening the local planning process to better integrate nutrition requires actions that address the key barriers identified while building on enabling factors. Further studies are needed on monitoring resource mobilization and implementation of CDP.