Abstract
OBJECTIVES: Eliminating malnutrition is on many countries’ political agendas but knowledge of how enabling environments are created and used is needed. We assessed the drivers of change in stunting reduction among children <5 y of age in Rwanda and contributors to differential reduction over 10–25 y. METHODS: We conducted in-depth interviews on changes in nutrition with nutrition stakeholders at national (n = 32), district (n = 38), and community (n = 20) levels, and community focus group discussions (n = 40) in 10 purposefully selected districts in Rwanda's 5 provinces. In each province, we selected 1 district with decreased stunting and 1 where no change or an increase occurred (2010–2015). We also used regression decomposition analysis to investigate drivers of change in stunting with Demographic and Health Surveys (2005, 2010, and 2015) data. RESULTS: Respondents believed peace and security along with improved leadership and decentralization helped to create an enabling environment for change. Rwanda experienced increased political and institutional commitment to nutrition indicated by adoption of a multisectoral policy and reinforced with horizontal coordination platforms and plans at national and sub-national levels, but greater financial commitment is needed according to respondents. Vertical coordination across administrative levels improved through communication, staff working on nutrition at these levels, and relationships between nutrition actors. From respondent reports, health and agricultural programs and increased availability and use of health services helped improve nutrition; differences between study districts included climate change challenges, food insecurity, weak horizontal and vertical coherence, and weak implementation of coordination plans. Supporting this, giving birth in a health facility, attending ≥4 antenatal care visits, antenatal care quality, fertility, parental education, household wealth, and health insurance coverage drove stunting reduction from the regression decomposition analysis. CONCLUSIONS: Leadership, commitment and horizontal and vertical coherence are important for creating enabling environments and providing programs and services that can lead to reduced malnutrition. FUNDING SOURCES: Ministry of Foreign Affairs of Kingdom of Netherlands through SNV Netherlands Development Organization.