Date of Award

Summer 2020

Document Type

Open Access Dissertation


Health Promotion, Education and Behavior

First Advisor

Edward A. Frongillo


Reducing undernutrition is on the political agendas of many low- and middle-income countries. There is general consensus that to improve nutritional outcomes involves actions across the different sectors that influence both the immediate and underlying determinants of optimal nutrition and an enabling environment to support the political and policy processes. Despite renewed attention over the last 15 years, addressing nutrition in a multisectoral way was previously promoted in the 1970’s but failed to have sustained political commitment due to its organizational complexities to plan and implement strategies across sectors.

We conducted an in-depth retrospective case study to understand how Rwanda, a low-income country with high burdens of undernutrition, achieved progress reducing undernutrition and how the country addressed the challenges presented by multisectoral nutrition strategies. We conducted a document review of nutrition and nutrition-related policies and programs since 2000, in-depth interviews 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 five provinces. In each province, we selected one district with decreased stunting (reduced districts) and one where no change or an increase occurred (non-reduced districts) between the two last Rwanda Demographic and Health Surveys (2010 and 2014/15).

After 2008, reducing undernutrition became a national priority in rhetoric, policy, and institutionally. Nutrition goals were gradually integrated into different sectoral policies and in national economic development strategies. Political commitment to nutrition was generated across sectors at national level and translated to sub-national levels where, because of the country’s decentralized governance system, mid-level leaders had increasing responsibilities for coordinating and implementing nutrition strategies. Institutional bodies were established to facilitate collaboration across sectors and actors at both the national and sub-national levels. At the sub-national context, we find that capacity in nutrition, nutrition monitoring and evaluation, and the implementation of coherence were reported to be more optimally implemented in the districts that improved stunting compared to the non-reduced districts.

The results from this study provide a narrative on how improvements occurred in Rwanda, a better understanding of implementing multisectoral nutrition strategies at the sub-national context, and the perspectives of the mid-level leaders and frontline workers coordinating and implementing multisectoral nutrition programs and services.