Prospective analysis of the development of the national nutrition agenda in Vietnam from 2006 to 2008 Free

Abstract

Improved understanding of how to advance national nutrition policy is critical to ensure greater policy investments in nutrition. We used a participant-observer, change-agent model to prospectively study why and how national nutrition policy advanced in Vietnam between 2006 and 2008. Our goal was to understand strategies used, factors that shaped policy advancement, and the interaction of strategies with factors in this context. Data were collected using questionnaires, informant interviews, programme visits, document reviews and documentation of key events. For analysis, we created a chronology of events, examined strategies and actions used and their results by event, coded interviews and summarized findings using a well-known framework for policy analysis. Our analysis shows that the following elements were critical to bring greater attention to nutrition policy in this context: (1) building a cohesive nutrition policy community through creation and support of an alliance; (2) clearly defining internal and external frames for the nutrition problem; (3) using and creating high-profile internal and external policy windows; and (4) capitalizing on cultural motivations and values. Findings indicate that that rapid nutrition policy advancement is possible if purposeful, contextually sensitive strategies are used where favourable conditions exist, or can be created. The participant-observer, change-agent model was successful in both contributing to policy advancement and documenting it.

Introduction

While past research has examined biological, epidemiological and implementation aspects of public health and nutrition policy (World Bank 2006; Bhutta et al. 2008; Black et al. 2008; Bryce et al. 2008; Morris et al. 2008; Victora et al. 2008), there has been limited empirically-based research on the sociopolitical factors that influence national policy formulation, including the ability to generate effective policy traction and resources. The sociopolitical dimension has been seldom analysed systematically, the tendency in nutrition and public health being to portray policy development as a technical or economic process (Ebener et al. 2006; Gilson and Raphaely 2008). This may in part be because policy decisions are complex, ambiguous and involve many actors with varying aims, perspectives and power (Sabatier 2007), and also because of limited training in the conduct of policy analysis.

The sociopolitical characteristics of public health, including nutrition, may be more significant in determining outcomes than biological, epidemiological and implementation characteristics (Shiffman 2007; Institute of Development Studies 2008). The journal Health Policy and Planning recently dedicated an issue to health policy analysis, recommending: (1) more explicit methodological focus; (2) better use of existing literature; (3) further research on agenda-setting and policy implementation; and (4) real-time, prospective, health policy analyses informed by strong theoretical and analytical frameworks (Buse 2008; Walt et al. 2008).

This paper responds to that call as well as to other identified gaps in the nutrition policy literature. We conducted a prospective health policy analysis of why and how Vietnam’s national nutrition agenda developed over a 2-year period (2006–2008) and, in particular, how the Plan of Action to Accelerate the Reduction of Stunting (PAARS) emerged as a new policy focus. This analysis addressed three questions: (1) What strategies were employed by actors to move the agenda forward? (2) What factors shaped the movement of this agenda? (3) How did these factors and strategies interact over time to move the nutrition agenda forward?

Methods

Study setting

The prevalence of stunting for children under 5 years of age declined substantially in Vietnam from 60% in 1985 to 30% in 2005. But, Vietnam has not improved as expected given rapid economic growth in recent years (Wagstaff et al. 2001), and there remain marked disparities, with the 64 provinces ranging from 6% to 50%. Vietnam ranks tenth globally in number of children stunted (UNICEF 2007).

Vietnam established the National Institute of Nutrition (NIN) under the Ministry of Health (MoH) in 1980 to co-ordinate research programmes on national nutrition problems such as protein-energy malnutrition, vitamin-A deficiency and iron-deficiency anaemia. In 1991, the MoH declared nutrition to be a national priority and NIN released a nutrition situation report. The Protein Energy Malnutrition Control programme was established and was initially implemented by the National Committee for Population, Family and Children, before programme responsibility passed to NIN in the 1990s.

Building on efforts to improve nutrition, the Prime Minister approved a National Plan of Action for Nutrition in 1995 which set priorities and goals for 1996–2000. The first National Nutrition Strategy (NNS) covered the period 2001–2010, with NIN responsible for oversight of its implementation, and work has commenced on planning the second NNS for 2010 and beyond.

Decentralization has been a prominent feature of recent development programmes enacted by the Government of Vietnam. While decentralization continues, central government still exerts significant control, especially in policy discussions. Donor funding comprises about 5% of Vietnam’s health budget, of which a small amount goes to nutrition programmes.

Methodological orientation

The World Bank’s Mainstreaming Nutrition Initiative (MNI) was designed to support and analyse nutrition policy processes in countries. In 2006, Vietnam was selected to be part of the MNI because of the potential to collaborate with several interested institutions working in the country (Menon et al. 2009). MNI funding supported the lead author who assumed the role of both participant-observer and change agent. Data were collected while the lead author, who had already worked in Vietnam for several years, was employed by an international non-governmental organization (INGO). She built upon established rapport with key actors, creating an entry point for the work, and closely engaged in policy discussions and programme implementation. As the main data-collection instrument (Bernard 1995), she obtained enhanced trust among partners and trustworthiness in findings because of: (1) access to data not available to those not in the community (2) reduced reactivity and change of behaviour in the presence of the researcher; and (3) enhanced intuitive understanding of what was taking place which allowed her to speak with more confidence about the meaning of data collected (Krefting 1991).

Data collection

From September 2006 to September 2008, a qualitative, case-study methodology using an in-depth longitudinal, prospective examination of events (Yin 2003) was employed. Case-study methodologies have a unique capacity to consider political and social phenomena in context and with attention to historical influences (George and Bennett 2005). Research questions were broadly defined and a variety of evidence sources identified. Data collection involved: (1) administration of a questionnaire on current nutrition programmes and research agendas to a variety of country nutrition actors; (2) 22 structured interviews with key nutrition policy and programme stakeholders (14 in 2006 and 8 in 2008); (3) visits to nutrition programme implementation sites; (4) review of government documents, donor agency reports, meeting records, conference proceedings and media clips; and (5) first-hand documentation of key events and meetings. Tufts University Institutional Review Board reviewed and granted exemption for this research.

The stakeholder interviews were conducted with representatives from government, academic institutions, NGOs, United Nations (UN) agencies and donors using an interview guide with six themes (Clark 2002): agenda setting, commitment building, intervention strategies, implementation, evaluation, and changing or terminating programmes. Two years after initial data collection, another round of interviews was done with key informants from the same agencies. Respondents were generally forthright thanks to familiarity with the lead author and the trust that had been established. Original questions were re-visited and enquiries made about specific actions taken in the prior 2 years. Enquiries also validated the timeline of events, actions and actor motives. The lead author attended key events related to nutrition policy and programming. Site visits were conducted to observe the nutrition programme implementation and to support understanding of how policy translated into programmes. Visits were predominantly in the central highlands and northern mountainous provinces, areas with large ethnic minority populations, high malnutrition rates, and programme-implementations challenges related to remoteness and limited infrastructure.

Data analysis

A chronology of events related to the nutrition agenda was developed which supported the analysis of strategies and actions pursued for those events. An ‘event’ was defined as an occurrence having significance in agenda-setting, involving multiple institutional players (e.g. a large advocacy meeting). An ‘action’ is indicative of an act that is done or performed, while a ‘strategy’ is a plan or method for obtaining a specific result.

Coding of interview responses and other data was done using transcripts and other textual documents based on these categories adapted from Clark (2002): (1) settings/context, (2) definition of the situation (problem orientation, problem solution), (3) perspectives, (4) process, (5) activities, (6) events, (7) strategies, (8) relationships and social structures, (9) methods, and (10) values. Consistency was enhanced by comparisons between multiple data sources. Coded data were mapped to an adapted version of a framework provided by Shiffman and Smith (2007), but data were retained even if they did not readily map to it. Primary factors that influenced nutrition agenda advancement were delineated, with a focus on factors that changed the most during the study period. Interpretation was member-checked by discussion with key actors (Krefting 1991).

Process tracing (George and Bennett 2005) was conducted using multiple sources of information, an in-depth understanding of the situation and informed judgments to minimize bias. This enabled the identification of patterns of causality and critical social and political processes. Analysis integrated views from three lenses: (1) which factors changed most and by what strategies; (2) which events and strategies were critical to the policy end-point; and (3) what was revealed about underlying conditions and causal links essential to success when the course of smaller events was tracked. Interpretation was checked by triangulating multiple data sources and discussion with key actors.

Results

Key strategies and actions

Five key strategies associated with effective agenda-setting were identified (Table 1). Orientation meetings with key national partners and international agencies galvanized support for the work and ensured the MNI activities were vetted and informed by local partners. This engendered local ownership and helped identify key national informants for the intensive situation analysis around identification of the sociopolitical, epidemiological and implementation barriers and facilitators to nutrition policy formulation in Vietnam.

Site visits to remote and ethnic minority areas of Vietnam enabled a better understanding of local political and logistical issues associated with translating policy into nutrition programmes and outcomes, and enhanced the credibility of actors and their opinions.

The situation analysis identified need for a policy community, and this was quickly acted on through formation of the Nutrition Partnership Group (NPG). The NPG held its first meeting in January 2007, and this ongoing dialogue forum was identified as influencing several different factors related to nutrition policy and programmes.

Targeted meetings with key players and within the nutrition community emerged as important (Table 1). The meetings internal to the nutrition community ranged from periodic formal and informal NPG meetings to the March 2007 MNI workshop that brought provincial and central actors together. A meeting sponsored by the United Nations Children’s Fund (UNICEF), held in September 2007, was also influential, and firmly placed a focus on stunting reduction on the table. Through 2007, opportunities for external advocacy events occurred with increasing frequency. Members of the National Assembly, the highest ‘representative’ political forum in Vietnam, attended the first-ever review of the National Nutrition Strategy in March 2007. Invitations to host high-profile global-nutrition events were welcomed by Vietnamese government officials; the launch in Hanoi of the Lancet Nutrition Series (Black et al. 2008) was planned for January 2008 and it was agreed that Hanoi would host the annual Standing Committee on Nutrition (SCN) meeting in March 2008. These events would not have taken place in Hanoi without the efforts of many of the key actors both in Vietnam and internationally.

Placement of the lead author was important. As one respondent stated, “human resources are a real need and having a dedicated technical person to focus on nutrition was critical to moving the nutrition agenda along”. Another respondent commented that the lead author served as a community organizer while the community allowed itself to be organized.

Key factors

Key factors were identified and described in four dimensions (Shiffman and Smith 2007): actor power, ideas, political context and issue characteristics (Table 2).

Actor power

Actor power describes the strength of individuals and organizations concerned with nutrition and the associated policy community, leadership, institutional and resource mobilization characteristics.

Policy community cohesion: In 2006 there was no co-ordinating mechanism for nutrition in Vietnam as existed for other health subsectors such as health financing and HIV. Nutrition activities and expertise were not concentrated in any one UN agency. While UNICEF and the World Health Organization (WHO) were involved in nutrition programming, the Food and Agriculture Organization (FAO) was focused on responses to the avian influenza pandemic, and the World Food Programme (WFP) was no longer present in Vietnam. International and national development partners had no specific venue for meeting or information exchange, and there was limited pro-active information-sharing from national partners. In response to this gap, the NPG was initially co-convened by representatives from the Asian Development Bank and Save the Children in January 2007. Participants included representatives from international agencies, NGOs and the Vietnamese government. Terms of reference were adopted and an initial set of actions outlined. One respondent stated that they are “now talking about a nutrition community; before there was no cohesive set of people to call on as colleagues in nutrition, now there is”. At a later stage, organization of the NPG was passed to UNICEF.

The NPG facilitated regular dialogue between the small number of international and national nutrition professionals based in Hanoi. The community was increasingly cohesive and organized in thought and action. For example, there was a co-ordinated response organized to a prominent article published in an English-language newspaper in 2008, which had described breastfeeding policies along with a picture depicting women obtaining samples from a commercial breast-milk substitute manufacturer. Within 3 days, a letter to the editor was sent with signatories from NIN and a number of international development partners asking for a correction. The newspaper issued a prominent response several days later. It was widely acknowledged that this kind of co-ordinated response would not have been possible before the days of the NPG.

Leadership: The nutrition community in Vietnam benefited from a charismatic leader at NIN with whom others could easily work. He was diplomatic and a skilled consensus builder, important qualities in Vietnam. He responded to suggestions from the NPG, provided leadership, navigated the complex political scene, and paid attention to the development of junior staff by prioritizing access to training at home and abroad. Two of the major donor organizations in Vietnam had health sector heads with academic backgrounds in nutrition, which translated into more engagement in nutrition by these leaders as demonstrated by regular interaction with NIN and the leadership of the NPG. Without the personal interest of these leaders, it is unlikely their efforts would have been the same given broader requirements of their positions.

Guiding institutions: NIN was challenged by needing to co-ordinate across multiple government agencies with some nutrition-related mandate, working in an increasingly decentralized environment and needing to be financially self-sustaining by 2012. Historically, NIN had focused on research, but its mandate had grown to include policy and programme responsibilities. In addition, NIN had to be responsive and a willing development ‘partner’ to any international institution or agenda that arrived and had an interest in nutrition. One respondent noted that these pressures and somewhat conflicting roles would grow as Vietnam transitions to a middle-income country, and there are higher expectations from donors about efficient project implementation. A review of the National Nutrition Strategy relates that 16 ministries or agencies have a role to play in nutrition; contacts were interviewed for this study in most of these ministries. Those respondents stated that nutrition was a key challenge in Vietnam, but they also noted they could do little without funding directed specifically to their agency.

Resource mobilization: Mobilization of human and financial resources for nutrition remains a challenge. One respondent from a donor agency stated that: “while health issues have made it as a front-page topic now, this wasn’t the case 10 years ago … [This] has changed mostly due to SARs, avian influenza, HIV etc. and rapidly growing middle class that demands responses from government. In my time in Vietnam no one has ever mentioned nutrition as a topic of great concern.” This respondent made this statement in the context of explaining that international resources in nutrition will not be invested in a country if nutrition is not promoted as a priority topic. A national respondent observed that key agencies, including the one she worked for, had reduced investments in nutrition in recent years.

Ideas

Ideas are internal and external frames, or ways in which actors portray and position issues to resonate with audiences.

Internal frame: Key actors interviewed saw major biological and epidemiological nutrition problems in Vietnam in a similar way. These included a high prevalence of stunting (although many of them seemed accepting of this in part because they felt powerless to affect it in the short term and assumed that it would reduce over time), low exclusive-breastfeeding rates, high anaemia prevalence and suboptimal experiences with food fortification. Generally, policies were thought to be in place, but in the international community there was mention that ‘lip service’ was paid to nutrition in Vietnam but little real action was taken. This assertion was echoed in the Vietnamese interviews. Solutions were similar from all respondents, including a stronger focus on actions at the provincial level and below, more capacity building throughout the system, the current national programme needed to be adapted, a co-ordinating mechanism needed to be created, and more and better analysis of the situation with current data was required. Given general agreement on the nutrition problem and solutions, efforts were invested in encouraging a focus on the most prominent nutrition issue (stunting) and the elaboration of appropriate responses.

External frame: Considerable work was invested by the NPG in ensuring a common voice from the nutrition community in ‘external framing’ of nutrition problems. The focus on stunting was suggested by key international donors at the MNI-hosted March 2007 workshop, and was adopted by the NPG as the way by which to externally frame the nutrition problem. Attention to stunting was reinforced at various advocacy events. The choice to focus on stunting was made for many reasons including: a data system for measuring stunting was in place; it was the most prevailing nutrition problem in Vietnam with compelling impacts on socio-economic development and even sports performance; it resonated with the technical community as it included other nutrition issues like poor infant and young child feeding practices and it has links to emerging public health nutrition issues like obesity; and it capitalized on cultural characteristics of competition and wanting to be a world leader in all aspects of development, including reductions in stunting.

Political contexts

Political contexts are the environments in which the actors operate. Policy windows or opportunities to promote the issue and governance structure are examined.

Policy windows: Several timely policy windows, including an MNI meeting, UNICEF meeting, Lancet launch and SCN meeting, were critical in the creation of PAARS. These policy windows served numerous purposes including creating a more cohesive community, drawing in others and advocacy. These windows were also the major venue for expressing the ‘external frame’ that had been developed by the nutrition community. A focus on stunting as the primary issue at these events and the call for a co-ordinated response exerted positive pressure on actors, both internal and external to the policy community, to commit to PAARS. This commitment was reinforced in various policy contexts by various actors like the Deputy Vice Minister of Health at the SCN meeting or head of UNICEF at the Lancet launch.

There were varied opinions among nutrition partners regarding costs and benefits of hosting some events. All were resolute that any event needed to further the shaping of the nutrition agenda in Vietnam. The Lancet launch in Hanoi had advocacy impact; from that event, more than 25 stories, half of which explicitly mentioned stunting as the main issue in Vietnam, were highlighted in various media outlets (GMMB 2008). The launch also called attention to content of the Lancet scientific papers. Some respondents thought that the launch had an “external feeling and little local ownership as it was externally managed and driven”, but they also saw benefits to the launch since it drew leaders in the nutrition community and wider Vietnamese government to the event. The Lancet launch and the SCN meeting that soon followed created more momentum for the creation of PAARS.

Despite some initial resistance from the international community to hosting the SCN meeting, NIN was committed to having the meeting in Vietnam. One respondent stated that “NIN deserved credit … they latched onto the idea when others didn’t want to support it … they went to Rome and announced they were going to have it. Clearly they saw an opportunity and seized upon it, they knew it was going to be a lot of work but they had confidence and dragged the rest of us along.” An employee of a UN agency stated that the SCN meeting was “very important, it confirmed a lot of technical information, people talked about stunting and the concept of the window of opportunity”. The Director of NIN shared the PAARS at the SCN, and the Government of Vietnam released a Ha Noi Declaration for the National Nutrition Actions that calls for the accelerated reduction of child stunting. The declaration also urged nations to add the target to reduce stunting into national action programmes and to make high-level commitments. A senior UN official who closed the meeting stated that he expected the PAARS to bring the country to fulfill the Millennium Development Goals by 2015 (MOH 2008).

Governance structure: To make progress in nutrition, sustained support from the National Assembly, the political entity that exerts the most influence and power in Vietnam, is needed. One respondent noted that “things have changed dramatically, there is more investment for nutrition now after the SCN meeting, the Vice Minister and MoH came recently and stated that they understood the issues more through the SCN meeting. The National Assembly has invited us to present the nutrition strategy; through this opportunity we will emphasize the stunting plan.” Another stated that there has been “change over the past two years, things are getting better, people are more awake, the public and the government. More authorities are putting nutrition on the agenda. Before community leaders would ask for houses and infrastructure, now there is a change in attitude and where funding would go … changed in part because of national assembly, then others follow … changes are likely due to a combination of things like SCN, NNS etc.”

Two recurrent challenges in nutrition are multisectoralism and decentralization. Multisectoral responses are needed to address the multiple causes of malnutrition. The current National Nutrition Strategy relates that 16 ministries have a role to play in ensuring sound nutrition in Vietnam. Despite its multisectoral nature, nutrition programming and policy is often developed and implemented through vertical structures, as in Vietnam. Decentralization is taking place in Vietnam, and while still a fairly centralized country, power is shifting to the provinces. The NIN is challenged to effectively support nutrition through enhanced capacity building of provincial partners within this context: “Support is needed from the Government of Vietnam and others … international agencies can offer technical capacity but attitudes of people need to change. We are used to being told what to do and are very dependent on central level, we need new ownership and fuller capacity … there are big changes with decentralization, provinces have a lot more power now.”

Issue characteristics

Issue characteristics are the features of the problem, including whether or not there are credible indicators to measure the issue, the severity of the issue, and if effective interventions exist to address the problem.

Credible indicators: Nutrition indicators like wasting (low weight-for-height) and stunting (low height-for-age) are often used internationally as proxy measures for how well a country is doing developmentally (World Bank 2006). Traditionally, underweight, a composite measure, was used by national nutrition programmes given its ease of collection. This practice has been criticized given that stunting and wasting have different etiologies and responses, and using underweight can obscure the understanding of the nutrition problem. Vietnam has data available on all three indicators.

Severity: While Vietnam compares well regionally with regards to some health indicators, like infant and under-five mortality, prevalence of malnutrition remains high for Vietnam’s stage of economic development (Wagstaff et al. 2001). Gains made in the health sector have not translated into the same kind of reductions in child malnutrition. About 36% of children under five are stunted, 8% wasted and 20% underweight (GSO 2006).

Effective interventions: Effective long- and short-term interventions exist to prevent and reduce malnutrition. In Vietnam, one respondent noted that the Lancet launch messages were “very important, including the refrain to do the right things and not do the wrong things”. The respondent continued to state that “the current food demonstrations in the national programme were the wrong thing and the PAARS would allow this to be changed”. The evolving process in design of the national programme will shed further light on whether or not there is agreement regarding intervention selection. There has been general agreement on major programme thrusts, but selecting delivery strategies and targeting interventions may be more difficult and contentious.

How and why the nutrition agenda moved forward?

The cohesion of the policy community changed dramatically from 2006 to 2008. In 2006, one respondent stated that the “international community has taken a divide and conquer approach”, while 2 years later all respondents noted that the community, both international and Vietnamese, had come together. Much of this is attributable to the formation of the NPG. The NPG, however, would not have been formed without having a dedicated person committed to organizing and supporting it, or a co-convener representing the largest country donor for nutrition with influence and respect. The NPG persists, and is being chaired by UNICEF. A series of high-profile events solidified cohesion and membership whether it was on the Country Planning Team for the Lancet launch or the Government-mandated Local Organizing Committee for the SCN. These events were critical to altering the political context.

The internal and external framing of the nutrition problem and solution evolved significantly over the study period. While problem orientation and solutions were fairly similar amongst respondents in interviews, a focus on reduction of stunting emerged. Efforts to enhance policy cohesion were also important for framing, both internal and external. Internal framing was enhanced by joint deliverables of the NPG which mapped the landscape of nutrition programming and policy in Vietnam. Networking by Vietnamese and expatriate nutrition actors was critical to create policy windows in Vietnam like the Lancet launch and the SCN. These key events had both an advocacy component and technical substance.

The March 2007 MNI and March 2008 SCN meetings were particularly important for internal and external framing. Success of these events was predicated on use of other strategies such as relationship building. For example, numerous joint trips between the lead author and a counterpart at NIN resulted in open, informal communication with an accessible insider’s perspective. For the lead author, this was into the Vietnamese nutrition community, and for the NIN employee, it was into the international agency community. The NPG was critical to this process moving forward as it established opportunities for the nutrition community to convene.

Two underlying elements present during this study emerged as being drivers of what happened: the importance of personal relationships with people in key institutions, and the ability to identify, create and make use of opportunities to catalyse the process. Pre-existing relationships and alliances were strengthened throughout this period, and new partnerships were founded through informal mechanisms (i.e. social events). While in other settings the development community (both international and national) has been plagued by rapid turn-over of staff, this 2-year period was one of relatively little turn-over amongst key actors. Additionally, what turn-over did occur was positive. Key agency positions that were replaced benefited from supportive and collaborative personalities that actively engaged in the on-going process. After the end of the formal study period, two critical actors from key agencies left their posts; there is evidence of institutionalization in that both of their replacements will continue with work as planned.

The ability of various actors in the nutrition community to identify, create and make use of catalytic opportunities also emerged as a driver of the process. Reliance on informed local collaborators and a deep understanding of context were important factors to actualizing these opportunities. For example, it became understood that competition was a powerful motivator in the country. Vietnam seeks to be a world leader, to perform well in any internationally compared assessment like the Millennium Development Goals, and to attract international events that present the country in a favourable light. Bringing the SCN meeting to Vietnam through effective networking both in Vietnam and Geneva proved successful because it utilized this desire to be an international leader, provided a forum through which to promote Vietnam’s successes, and, without being critical, created pressure that Vietnam perform even better. Utilizing this catalytic opportunity required prior contextual knowledge of values and motivations regarding what decision makers deemed to be important, and the ability to provide resources, contacts and other means to make it happen.

Discussion

In 2 years, remarkable progress was made in the development of a new national nutrition strategy. Key factors identified as important to the agenda-setting process were the emergence of a cohesive policy community and clearly defined internal and external frames, articulation of which was facilitated by a series of high-profile events that functioned as policy windows. Strategies that capitalized on cultural motivations and values were effective. High-profile events that mobilize political attention can be used strategically by a policy community to facilitate country-level progress. Underlying elements such as individual relationships within a policy community can significantly affect success or failure of specific strategies.

The findings fill knowledge gaps around how a particular public health issue, such as malnutrition, can ascend in a broader landscape of policy issues. These knowledge gaps have been highlighted consistently where it is noted that biological and operational aspects of nutrition programmes are well understood, and yet significant scale-up does not occur (World Bank 2006; Morris et al. 2008). A lack of sustained government commitment and low demand from communities is identified as a constraint (Horton et al. 2009), but there has been little documented experience on how to alter these factors.

The framework used (Shiffman and Smith 2007) was helpful to organize key factors. Consistent with other research uses of the framework, not all factors needed to be strong or to change significantly to actualize policy progress. The framework-based description was complemented with analysis of the values, motives and relationships among key policy actors. Together, this enabled a better understanding of how issues and proposals can attain greater prominence on policy agendas.

We demonstrated effectiveness of the participant-observer change agent in policy research for both shaping and studying the policy process (Walt et al. 2008). How a participant researcher ‘is viewed’ or situated, the institutional base, perceived legitimacy and prior involvement in a policy community proved critical to the ability to conduct meaningful research, especially where engagement with policy elites was required. We mitigated the potential limitations of the lead author’s dual role through triangulation of data sources and member checks.

With increasing calls for rapid communication of research results for policy-making, there are growing expectations that researchers engage in research translation and as policy actors (Walt et al. 2008). Thus, researchers need to be more reflective about their role in that process and for these experiences to be well documented and analysed.

Our finding that a public health issue does not necessarily receive greater attention or resources even when there are compelling characteristics such as severity, effective intervention options and credible indicators is consistent with other research (Working Group on Priority Setting 2000; Shiffman 2006). While nutrition interventions are consistently ranked as excellent investments, commensurate resources and policy support do not often follow. This reality suggests that further examination and data collection in relation to the sociopolitical characteristics of an issue is needed.

Research on funding flows and donor priorities across key public health issues has determined that ‘interests of individual nation-states cannot be understood by considering domestically oriented concerns alone’ (Shiffman 2006). International actors, including public and private donors, can significantly influence a national health agenda through personal or organizational agendas and with view to broader regional and global public health concerns. This suggests that public health issues that determine attention at global level may also be readily addressed at country level. This paper has described significant policy progress at country level with country actors taking the lead in collaboration with international actors. This finding should inform global efforts to strengthen what recent literature has referred to as a ‘fragmented and dysfunctional’ international nutrition system (Morris et al. 2008).

Advancement of nutrition policy is possible when key factors are favourable, thoughtful strategies are used and the international community supports country leaders to frame their own agenda. Agenda-setting was necessary but not sufficient to actualize better nutritional outcomes in Vietnam. Despite turnover among the actors in the nutrition policy community, including leadership at NIN, this policy development process persisted. Against the overarching political prioritization of decentralization, translation of new policy to programmes and nutritional outcomes will require skilled attention to intervention selection and targeting, health system integration, and capacity and funding. Rigorous prospective evaluation of the transition from agenda-setting to programme implementation should support this process. Vietnam has begun work towards these next steps of policy translation, which will take place in the context of the existing national nutrition programmes such as the Protein Energy Malnutrition Control and involve actors at multiple levels.

Funding

This study was supported by the World Bank as part of the Mainstreaming Nutrition Initiative.

Conflict of interest

We declare that none of the authors or their organizations has any conflict of interest in the publication of this paper.

Acknowledgements

This study was supported by the World Bank as part of the Mainstreaming Nutrition Initiative that was hosted by ICDDR,B. We also acknowledge the support of Save the Children Vietnam and Dr Pham Bich Ha and Ho Ngoc Anh in particular. The National Institute of Nutrition in Vietnam and national and international partners were of great assistance.

References