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For countries looking to implement multisectoral nutrition plans, it is critical to understand what works and how programs should be delivered and scaled-up in each context. Programs can learn from each other on how to adapt to new information, evidence and events related to scaling-up and district stakeholders can play important roles in implementation of this multisectoral plan. As part of "Pathways-to-Better Nutrition" (PBN) case study conducted by USAID/SPRING Project, this research set out to explore district leaders’ perceptions of the nutrition situation, programs and opportunities for integration. Qualitative data were collected through key-informant interviews and focus group discussions. Thirty-five district and local leaders belonging to district and sub-county multisectoral nutrition committees in Kisoro and Lira were interviewed. Grounded Theory Approach was used to identify themes for coding and key domains included: learning, adoption and evidence of scale-up; adoption of innovations/interventions to local context, financing of nutrition-sensitive activities and long-term planning. Additionally, quantitative data collected by Feed the Future Innovation Lab for Nutrition were analyzed in each of the districts to provide nutrition snapshots. Malnutrition in the study districts was worse than the national average for stunting, anemia and women’s underweight. The majority (91%) of respondents were not familiar with these nutrition statistics. Both study areas have formed nutrition multisectoral working groups (District Nutrition Coordinating Committees) and have developed management structures to implement interventions. Government stakeholders from every nutrition-sensitive sector referred to the lack of clear government programs that support nutrition directly in local policy environment. Key agricultural-related programs are focusing on wealth creation, value-addition or increasing agricultural productivity without nutrition lens (not “nutrition sensitive”). Nutrition is not on the ‘list’ of key priorities of district health departments unlike HIV/AIDS, malaria or sexual reproductive health. About 69% respondents believe they lack operational capacities and soft-power skills to design, implement and manage nutrition interventions such as leveraging of resources and being able to convey evidence. The understanding of “Scaling-up Nutrition” also differed by respondent, and this has resulted in different goals and measurements. Challenges related to nutrition financing were also noted, including fiscal decentralization, use of Output-Based Financing mechanisms, limited flexibility to re-allocate funds for nutrition, and lack of standard reporting procedures or implementation strategy. Efforts to address malnutrition need to be multisectoral, coupled with increased coordination of different sectors and ministries for sustained impact on nutrition outcomes. Keywords: Pathways, nutrition, scaling-up, multisectoral, coordination, nutrition action plan, district, Uganda

Understanding pathways to better nutrition at district level: Lessons from Uganda