Factors influencing delivery of intersectoral actions to address infant stunting in Bogotá, Colombia – a mixed methods case study

Intersectoral actions (ISA) are recognized relationships between part or parts of the health sector and part or parts of another sector to act on health-related issues in a way that is more efficient and sustainable than could be achieved by the health sector alone [1]. This requires considerable coordination efforts and questions the durability of ISA, what Greer and Lillvis described as “bureaucratic obstacles to intersectoral governance” [2]. For this reason the study of ISA involves detailed attention to plans for monitoring, evaluation, and accountability of the collaborative efforts, with a focus on the importance of soft skills available within the partnership such as communication skills [2‐4].

Although ISA is a frequent topic in public health studies, documentation on systematization and implementation is scarce [2, 5‐7]. Discussions on the social determinants of health need to unravel the complex forms of intersectoral policy action since health is related to many different institutions and sectors of society [1].

Malnutrition is an example of the call for ISA, and a common topic in governmental agendas that highlights the need for public-private partnerships [8]. Stunting is a form of malnutrition characterized by a low height-for-age that leads to irreversible damage including shorter adult height, lower attained schooling, and reduced adult income [9]. The evidence indicates that stunting is a complex problem demanding action from multiple sectors [7, 10‐13]. Global efforts to reduce stunting with an intersectoral approach demand greater attention to communication and articulation of objectives and methods within the different sectors involved in order to accomplish the nutritional goals [7]. A recent systematic review showed that stunting was reduced by multisectoral efforts directed towards community-based nutrition with a strong emphasis on nutrition-sensitive and nutrition specific programs [14]. A recent systematic review by Aguilera and Daher collated macro-level policies and programs for stunting across government, health, and social assistance sectors of several countries including Peru, Malawi, Ethiopia, and Nigeria [14]. Thus, other sectors such as agriculture, social assistance, health, education, water and sanitation, and the private sector have been identified with technical competencies to maximize nutrition results [7]. However, identification of the various sectors’ responsibilities and roles does not necessarily mean that effectiveness of ISA is guaranteed, nor that a favorable environment for collaboration between sectors ensues.

Conditions for ISA include political will, legislative support, health sector engagement, local health service decentralization, motivation of human resources, and social participation [6]. These conditions for ISA has been exemplified in countries like Indonesia, where the National Strategy to Accelerate Stunting Prevention (StraNas Stunting) recognized that coordination across all levels of government was critical to align incentives across national, regional, and local governments [15]. Recognition of health as a collaborative outcome, management approach, teamwork skills and techniques, are all factors that trigger ISA [6]. In this regard, the literature regarding ISA implementation emphasizes that sectors must overcome the challenging task of facilitating meeting points across departments and hierarchical levels [16].

Only 19 out of 46 Latin-American and Caribbean countries have reported information on stunting, wasting, and overweight in children under 5 years old between 1985 and 2014 [17]. In 2015, the prevalence of stunting in Colombian children under 5 years old was 13% in the capital city, Bogotá, and 10.8% nationwide [18].

In 2018 and 2019 infants with, and at risk of, stunting were identified in three localities of Bogotá by an intersectoral intervention from government, health, social assistance, and private sectors [18]. In Bogota the provision and administration of health, education and social services are devolved services overseen by the corresponding District Secretariats under the coordination of the Mayor’s office.

The specific aim of the intervention was to promote interaction between the health and social assistance sectors in order to standardize nutritional practices and harmonize knowledge of infant and young child feeding (IYCF) national guidelines across these sectors. It had four main focus points. First, to provide access to good quality health services and the training of health professionals in IYCF practices. Second, to enable access to social assistance programs and training of social assistance professionals in good IYCF practices. Third, to educate caregivers in nutrition practices. Fourth, community empowerment to address stunting. The private sector played a key advocacy role by liaising with stakeholders, providing financial support and access to human resources for implementation of the intervention.

The intervention was developed as a “before and after” study to assess the change in anthropometric measurements of infants identified at risk of stunting or already stunted. The intervention also had an educational component in nutrition for parents and caregivers and was supplemented with food vouchers for those participants. In parallel, this case study was conducted to identify factors that facilitated or limited ISA implementation in Bogotá. The research used concepts extracted from The National Ministry of Health Guidelines for ISA [6]. Definitions are described in a supplementary table (see Annex 1).

The case study was developed using a concurrent mixed-methods design, with the qualitative component giving context to the quantitative results in order to identify factors that facilitated and limited demands, conditions and triggers for ISA in the intervention. We conducted workshops, focus groups, and semi-structured interviews. With the adaptation of two questionnaires, we sought the opinion of the participants to define the best ISA scenario to address stunting and optimize the intersectoral functioning of the partnership. A convenience sample was selected from representatives of the health, social assistance, education, and private sectors. Parents and caregivers also participated. Selection required understanding the purpose of the intervention. A total of 122 individuals participated in this study. Invitations to participate were sent via text message or by phone call. Figure 1 summarizes the units, data collection instruments and timeline of the study.

Forty out of 124 representatives participated in the workshops for a response rate of 32%. Sixty-five out of 90 parents and caregivers participated in the focus groups for a response rate of 72%. Seventeen of 18 of all intended participants in the semi structured interviews attended personally for a response rate of 94%. Thirty-three out of 99 participants of workshops, focus groups and interviewees answered the questionnaire regarding their general opinion of stunting for a response rate of 33%. Nine out of 10 members of the intervention committee answered the questionnaire of ISA for stunting for a response rate of 90%.

Factors related to the failure to achieve the potential height-for-age were most frequently ascribed to family income (76%), food quality (76%), and health services (64%). The most frequent conditions for ISA addressing stunting in the three localities were the need for local government coordination between the involved sectors (66.6%), the capacity and authority to guarantee infant nutrition services by the health sector (57.1%), and sufficient resources for the intervention (54.8%). Other factors conditioning ISA for stunting were the need for motivated and IYCF qualified human talent across sectors and an alignment of IYCF guidelines between sectors.

Finally, triggers for ISA were ascribed to the perceived importance of health outcomes by each of the participating sectors (69%), that coordinated and participatory ISA are explicitly promoted (64.3%), and that ISA guarantee interactions between sectors by work group dynamics and/or community participation (59.5%). Results are shown in Table 1.

The responses to the adapted “Checklist for Intersectoral Partnerships for Health Promotion” [21] (Annex 5) showed higher agreement between members of the intervention committee in the categories: Need for the partnership, Mission, Context, Resources, Leadership, Roles and structures, and Partners’ profile (Fig. 3). Members of the committee agreed that strengths were:

Categories that showed lower agreement were Communication and Partnership functioning. Members of the committee agreed that weaknesses were:

A summary of strengths and weaknesses of the partnership functioning are described in Fig. 3.

To our knowledge, this case study is the first to examine facilitating and limiting factors of ISA in the implementation of a stunting intervention, a prevalent but highly preventable public health problem. The intervention was facilitated by an acknowledgment of the need for intersectoral collaboration, political will, motivated human resources, management skills, and recognition of health as a collaborative outcome. Limiting factors were barriers to the timely summoning of some sectors, a lack of legislative support, insufficient engagement of the health sector, scarce local health decentralization, and barriers for social participation.

Colombia has established ISA as a core tool for development and promotes monitoring and evaluation of ISA to achieve the Sustainable Development Goals (SDG) [22]. There is an emphasis worldwide on documenting the challenges in ‘implementation’ of ISA and their ‘effectiveness’ of outcomes [4, 5, 23]. However, ISA for childhood programs and services have shown there is a need to ensure convergence between sectors and within a variety of programs to attain the common objectives [23]. Thus, prevention and management of stunting demands efficient coordination of ISA to reduce all forms of malnutrition, and to achieve a 40% decline in the number of stunted children under 5 years in Colombia by 2025 [24].

The conceptual framework for stunting by the World Health Organization [20] has previously highlighted that the factors identified demand ISA to address stunting. The context that affects stunting is molded by political economy, health and healthcare services, education, society and culture, agriculture and food systems, and water, sanitation, and environment [20]. In our case study family income was a key underlying factor for stunting. The intervention developed in Bogotá did not cover all of the structural social determinants of stunting. At the juncture of defining sectors related to infant nutrition, those directly involved were the health and social assistance sectors, and private institutions that shared infant nutrition as their mission. However, the literature also supports the importance of including economic factors for optimal linear growth. Children living in poverty lack the appropriate care, stimulation, or nutrition required to promote their development [25].

Research on ISA to address stunting suggests that the government sector should take a leadership role for coordinating ISA [11, 26]. The city of Bogotá has recently delivered a remarkable performance with ISA by achieving an absence of deaths by wasting in children between 0 and 5 years old [27]. This was accomplished by means of ISA strategies described in the literature [28]. The health sector provided therapeutic formula and assistance to prevent child mortality. Legislative support summoned sectors that aided food safety. Intersectoral action in local nutrition committees allow identification and follow-up the cases of child wasting. Social participation strengthened community networks working towards food safety. Notably, the lack of some of these conditioning factors were outstanding barriers for the planning and implementation phases of the stunting intervention. There is a challenge to summon ISA for stunting which does not raise the same degree of awareness as wasting does, especially in the context of declining nutrition-related child mortality [25].

A further conceptual point for discussion regarding differences between intersectoral and multisectoral interventions for stunting arises from the analysis of factors that condition ISA. Nutrition-specific interventions rely on the health sector [7] but there is ample recognition that many additional sectors have roles to play in nutrition-sensitive interventions [11, 29‐31]. During planning and implementation of the intervention against stunting in Bogotá, a lack of engagement of the health sector was frequently seen as a barrier for ISA. This may stem from a misconception that health professionals play the pivotal role in infant nutrition. This raises the question of whether the health sector should lead an approach that tackles a nutritional condition rooted in social determinants. Kim et al. have shown that the health sector usually controls the review of indicators thereby limiting the notion of health as a collaborative outcome, in itself a trigger of ISA [4]. More evidence is therefore needed to understand how sectors summoned to address stunting are more effectively interconnected [32].

Recognition of health as a collaborative result triggered ISA in the intervention. Pelletier et al. showcased the difficulties that Peru, Bolivia and Guatemala faced in policy formulation and translation into concrete operational plans [33]. In this regard the World Bank pointed out that sectors should include explicit nutrition indicators in the design phase of interventions [7]. This would help reduce concerns over failure to accomplish sector-specific goals, and remove limits to joint planning and coordination that frequently hinder ISA [4, 12].

Greer and Lillvis argue that obstacles for intersectoral governance are related to coordination and durability, and that solutions lie in enhanced political leadership, bureaucratic change, and indirect strategies such as expanding the range and capacity of people who have access to data, including ordinary citizens [2]. In the context of public-private partnerships of varying and separate organizational regulations, achieving appropriate intersectoral and interprofessional collaboration is complex, especially in private–public engagements [3, 34]. A first step for ISA resides in information quality and sharing among sectors, which is known as informative ISA [6]. Thus, each sector must have clear roles before implementation to avoid barriers and particularly to pre-empt issues with information system management and data sharing [8].

The benefits of ISA to tackle stunting were never questioned by workshop participants and interviewees, nor were the high demands needed for partnerships and synergies. There were however concerns over how to implement ISA. A similar situation was explored in an ethnographic study by Holt et al., who challenged the notion that ISA can be more discursive than practical and thus difficult to implement [5]. Although initiatives for intersectoral or multisectoral strategies to tackle stunting may be approved by the parties concerned, there is a clear need to understand and implement them beyond political will [35].

Lessons learned from this study that may be applicable to other settings are:

This study must be interpreted acknowledging some limitations:

Prevention of stunting demands ISA at its core, and although the mechanisms to couple actions from the different sectors are well described in the literature, these must be applied within the context of the local actors. This mixed methods case study has highlighted factors related to ISA function, and how stunting was positioned in the government’s agenda and in the mission of the social assistance, health and private sectors in Bogotá, Colombia.

The ISA are highly valued but a lack of coordination and management skills jeopardizes the implementation of the complex interventions needed to integrate the different sectors. Information access and data sharing are pivotal. Constant communication, without losing sight of the demands, conditions, and triggers of ISA, ensure that examination of facilitating factors and the timely resolution of limiting ones results in an effective implementation.