key: cord-0985417-04lsng6o authors: Coile, Amanda; Wun, Jolene; Kothari, Monica T.; Hemminger, Carolyn; Fracassi, Patrizia; Di Dio, Debora title: Scaling up nutrition through multisectoral planning: An exploratory review of 26 national nutrition plans date: 2021-06-08 journal: Matern Child Nutr DOI: 10.1111/mcn.13225 sha: 24e5741e5fd8af589f96663c5b530e6b514f8930 doc_id: 985417 cord_uid: 04lsng6o With a growing consensus on the need to address malnutrition in a comprehensive and multisectoral way, there has been increased attention on the processes and factors for multisectoral nutrition planning to be successful. To guide countries, the Scaling Up Nutrition (SUN) Movement developed a checklist that defined characteristics of good national nutrition plans. This exploratory review used the framework of the Checklist to assess 26 national multisectoral nutrition plans (MSNPs) developed between 2014 and 2020. The MSNPs were assessed against a subset of 31 Checklist characteristics defined as basic plan components. Although the level of detail varied across the reviewed plans, the majority included core components that are important to facilitate effective planning and implementation, such as an assessment of the nutritional status and determinants of malnutrition for children under 5 years of age, a commitment to global recommendations related to reducing malnutrition, actions consistent with global evidence and responding to identified issues/gaps, governance arrangements to facilitate coordination, and identification of capacity‐building needs/actions to support effective implementation. Common gaps across plans included risk analysis and mitigation, defined responsible agencies for each action, an assessment of the financial gap and defined mechanisms for financial tracking and resource allocation, and mechanisms to coordinate operational research. These findings provide a high‐level, multi‐country review of multisectoral nutrition planning that can support future policymakers, technical assistance providers and regional and global stakeholders to consider the foundational elements of and further validate and address common shortcomings in developing such a plan. With renewed focus on global nutrition-and the dawn of the third phase of the Scaling Up Nutrition (SUN) Movement (2021 Movement ( -2025 (SUN Movement, 2020b)-it is an opportune time to assess national efforts to combat malnutrition across countries. Within the global effort to improve nutrition for all, it has been widely recommended that countries adopt national multisectoral nutrition plans (MSNPs) that call attention to the importance of the '1000-day window' of a mother's pregnancy to the child's second birthday, as well as provide a framework for coordinated cross-sectoral scale-up of action (Bezanson & Isenman, 2010; Bryce et al., 2008; Gillespie et al., 2013) . Although the idea of developing national MSNPs has existed since the 1970s, early efforts had high rates of implementation failure due to ineffective coordination of actions by the multiple sectors involved (e.g. health, agriculture, social protection and education), the inability to significantly ramp up actions for nutrition, an overemphasis on elaborate and costly collection of data and overambitious sets of nutrition actions in countries with minimal capacity and resources (Berg, 1987; Field, 1987; Jonsson, 2010; Nisbett et al., 2014) . Since the 1990s, the enabling environment for multisectoral nutrition action has improved both globally and within countries. There has been growing evidence around determinants of malnutrition with an increased understanding around the direct and indirect factors that influence nutritional outcomes (Black et al., , 2008 Shekar et al., 2017; Victora et al., 2021) . Also, various global coordination efforts (International Food Policy Research Institute, 2015) have reaffirmed access to safe and nutritious food as a fundamental human right (FAO, 2005) and highlighted the importance of ensuring good nutrition as a 'human capital investment' (Shekar et al., 2017) additional nine countries were in the development process (SUN Movement, 2019) . In recent years, the increase in political momentum among countries, donors and other stakeholders to implement comprehensive nutrition plans has been accompanied by a renewed focus on the policy features and implementation processes that enable their success. As the SUN Movement's second phase strategy period draws to a close, it is important to consider how countries are translating their nutrition agendas into planning documents and to assess the relative key strengths and gaps across these plans to inform crosscountry knowledge, learning and future guidance. Although there is growing literature that explores the role of nutrition planning in advancing the nutrition enabling environment and progress on nutritional outcomes (Acosta & Fanzo, 2012; Fracassi et al., 2020; Heidkamp et al., 2021; Lamstein et al., 2016; Michaud-Létourneau & Pelletier, 2017; Ouedraogo et al., 2019; Pomeroy-Stevens et al., 2016) , there is limited multi-country literature exploring how and to what extent countries are translating global guidance around nutrition into multisectoral country planning. This exploratory review assesses 26 SUN countries' national MSNPs using a defined set of basic characteristics of a quality MSNP. The analysis provides a cross-country perspective on common characteristics and gaps in MSNPs, which can inform country knowledge and learning as well as global efforts and guidance. This assessment was based on qualitative reviews of a selection of SUN member countries' national MSNPs. Commissioned by the SUN Movement Secretariat (SMS), this review was conducted to provide the Secretariat with information to support SUN country planning. Plans were prioritized for review by the SMS based on (1) if they were developed between 2014 and 2020, (2) if they were current and active at the time of review, and (3) if they were accessible. Some countries were further prioritized if they had plans that were recently or soon-to-be expired (with a new iteration of the plan in development) or if they were recently or soon-to-be formally endorsed (and entering into operational planning). Given no human subjects were involved in this review, an institutional review board was not needed. To systematize the review process, the assessment was based on the SUN Movement's Checklist on the criteria and characteristics of 'good' national nutrition plans-a set of guidelines for policymakers • More than half of the 62 SUN countries have elaborated an MSNP, which contributes to strengthening an enabling policy environment for nutrition. • Countries have come a long way in multisectoral nutrition planning, with the majority of reviewed MSNPs including core elements important for effective nutrition planning and implementation. • Common gaps, such as risk analysis and mitigation, financial assessment and planning, and defined responsible agencies for each nutrition action, may foreshadow challenges with operationalization. • Resource mobilization efforts and evidence-based prioritization are crucial, particularly in view of the current COVID-19 pandemic. on key elements a plan should contain (SUN Movement and UN Network, 2016) . The Checklist was developed by the UN Network for SUN and the SMS, together with a group of experts in a wide range of policy areas. The Checklist is organized around five general areas considered to be the foundation of a national MSNP-including (1) situation analysis and policy/programming review, (2) stakeholder engagement and political commitment, (3) costs and budgetary framework, (4) implementation and management arrangements, and (5) monitoring, evaluation, operational research and review-each of which is further divided into two to six criteria, resulting in a total of 17 criteria (Table 1) . Additionally, each criterion lists several specific characteristics. However, the Checklist acknowledges that these are purposefully generic and not prescriptive to facilitate consideration and adaptation across country contexts. T A B L E 1 Areas and corresponding criteria of the national nutrition plan checklist Area Criterion AREA 1: Situational analysis and policy and programming review Criterion 1: The national nutrition plan provides a situation analysis of the nutrition context at national and subnational levels (including political, social, cultural, gender-based, epidemiological, legal, governance and institutional issues) Criterion 2: The national nutrition plan sets out goals and objectives, which are associated with specific, measurable, relevant and time-bound nutrition impact targets and results for target populations that are consistent with human rights standards and international recommendations and contribute to improving equity in achieving nutrition impacts Criterion 3: The national nutrition plan provides clear links to other nutrition-relevant sectoral strategies, plans and financing arrangements Criterion 4: The national nutrition plan describes the planned priority actions aimed at achieving nutrition impacts for all forms of malnutrition and are feasible, sustainable and locally appropriate, based on evidence and good practice, and are in line with human rights priorities Criterion 5: The national nutrition plan includes an analysis of risks and proposed mitigation strategies including measures to address emergency needs Criterion 6: The national nutrition plan describes governance, accountability, management and coordination mechanisms AREA 2: Stakeholders' engagement and high-level political commitment processes Criterion 7: The national nutrition plan describes the multisector and multi-stakeholder involvement in the development of the final document Criterion 8: The national nutrition plan has clear indications on the high-level political commitment to the endorsement and the implementation of the plan AREA 3: Costs and budgetary framework Criterion 9: The national nutrition plan sets out a financial framework that includes a comprehensive budget/costing of planned actions for national and subnational levels and demonstrates efficiency and effectiveness of the included programmes and interventions Criterion 10: The national nutrition plan includes a financing analysis. If the plan is not fully financed, it highlights agreed priority options for the achievement of the set nutrition impact targets and associated results Criterion 11: The national nutrition plan describes the mechanisms to allow the tracking of budget and expenditure data for nutrition across sectors and partners for decision-making, oversight and analysis on nutrition finances Criterion 12: The national nutrition plan describes how funds and resources will be deployed to sectoral budget holders, to partners and to the subnational level AREA 4: Implementation and management arrangements Criterion 13: The national nutrition plan describes the operational framework, which includes the implementation arrangements, with detailed roles and responsibilities of the government and partners Criterion 14: The national nutrition plan describes the individual, organizational and institutional capacities (both functional and technical) required to implement planned actions and spells out how capacities will be strengthened AREA 5: Monitoring, evaluation, operational research and review Criterion 15: The national nutrition plan includes a monitoring and evaluation framework that is sound, draws from sectors' monitoring and evaluation systems and includes core indicators; sources of information; methods; and responsibilities for ethical data collection, management, analysis, quality assurance, learning and communication Criterion 16: The national nutrition plan describes the mechanism for joint periodic performance reviews on nutrition to present programmatic and financial progress and for discussion on the findings for decision-making and actions Criterion 17: The national nutrition plan sets out the processes and institutional arrangements for operational research and for the rigorous documentation and dissemination of good practices and lessons learned (including both successes and failures) however, the analysis presented in this publication focuses on the results for the basic characteristics (31 in total). Select additional results are presented in the discussion section to provide further context or detail where helpful. Analysis was conducted in Microsoft Excel over two phases, the first initiated in 2018 (15 plans reviewed) and the second initiated in 2020 (11 plans reviewed). Twenty-six national MSNPs from SUN countries were shared by SMS for this analysis ( Table 2 ). The results highlight that 18 plans represented the first MSNP for the country, as could be determined based on the plan documents. All but six plans were considered final and/or were officially endorsed by the national government at the time of the review. In addition, 21 of the 26 plans had or referenced the intention to develop supplementary plans and frameworks that were intended to complement and add operational detail to the national plan document but were not analysed for this study. The percentage of analysed plans fulfilling each of the Checklist's basic characteristics are summarized in Table 3 by Checklist Area. The rest of this section describes these basic characteristics and results in greater detail. The relevant criterion number is indicated in parenthesis for ease of reference to Table 3 . All 26 plans included a situation analysis (Criterion 1) that summarized the specific nutrition issues in the country. All but one plan (96%) fulfilled the basic characteristic of describing the nutritional status and determinants of malnutrition for children under 5, although disaggregation of this data varied. For instance, 22 of the 26 plans (85%) disaggregated this information by either sex (58%) or region (77%). Beyond the nutrition situation, most plans presented at least some linkages to other sectoral strategies or planning arrangements from nutrition-relevant sectors (Criterion 3): 24 out of 26 plans (92%) reviewed past and current sectoral efforts, and all but one plan also included some documentation of the gaps or lessons learned from those sectors or previous national MSNPs generally. Plans varied in terms of which specific nutrition-relevant sectoral responses were discussed as follows: health (92% of plans), agriculture (77%), social protection (69%), education (65%), food security and livelihoods (58%), water, sanitation and hygiene (54%), gender and women (19%) and local development (8%). All plans included goals and objectives (Criterion 2) that were consistent with international recommendations-with commitments to reduce hunger and improve nutrition for its population. Less than half of all plans (12 of 26 plans or 46%), however, included targets consistent with all six World Health Assembly (WHA) nutrition targets for 2025. All of the targets in 21 of the plans (81%) were specific (named the specific measure of malnutrition to be reduced), measurable, relevant (to reducing malnutrition) and time-bound (specified the year that the target should be achieved). Regarding nutrition actions (Criterion 4), nearly all plans (23 out of 26 or 88%) proposed actions that were largely in line with global recommendations (in particular, the nutrition-specific interventions cited in the Lancet ) and included at least some actions that responded directly to issues identified in the situation analysis and were relevant to gaps indicated by the policy and programming review. Furthermore, all plans proposed at least some specific actions to overcome noted bottlenecks, including those related to planning (100%), equity (85%), regulation enforcement (81%), financial sustainability (73%) and human resource management (62%)-although plans varied in the level of specificity and comprehensiveness across these. Further, documented risk mitigation (Criterion 5) for obstacles to plan implementation, including in the context of emergencies, was noted as a gap across the plans. For instance, only nine plans (35%) considered and planned for risks to the implementation of the plan. Further, preparing for nutrition and food security emergencies was also not well-defined across most plans: Whereas importantly over half of plans noted the development or strengthening of an emergency plan (54%) or proposed a food security early warning or monitoring system (58%), only 10 plans (38%) mentioned both. Importantly, the majority of plans detailed governance mechanisms (Criterion 6) for the plan. All but two plans described the formation of specific governance bodies at the national level to manage and provide strategic direction to implementation, and 22 out of 26 plans (85%) described the formation of similar bodies at the subnational level-but almost always with less detail than at the national level. Regarding stakeholder involvement, all plans evaluated were mul- • Disaggregates information by sex or region 22 (85%) • Consistent with international recommendations (e.g. Sustainable Development Goals) 26 (100%) • Includes goals that contribute towards all six WHA targets 12 (46%) • Are specific, measurable, relevant and time-bound b 21 (81%) 3. Links to other strategies • Describes past and current nutrition actions from at least one sector beyond health or food security. • Describes priority gaps/lessons learned for the sectors included in the plan, or systemwide issues 25 (96%) • Includes actions consistent with global evidence and identified issues/gaps. 23 (88%) • Describes actions that address at least two types of bottlenecks in the enabling environment (e.g. equity, financial, human resource management, planning or regulation enforcement bottlenecks) 25 (96%) • Identifies risks to plan implementation and approaches to mitigate them 9 (35%) • Includes emergency planning and development of food security monitoring system 10 (38%) • Includes cost estimates of governance mechanisms at national level 13 (50%) • Includes cost estimates of governance mechanisms at subnational level 13 (50%) • Includes estimate of the financial gaps for costed actions 7 (27%) • Describes financial tracking mechanism including on-and off-government budget funding, plus allocations and expenditures 4 (15%) • Includes criteria for resource allocation 6 (23%) • Includes nutrition-specific and nutrition-sensitive indicators 19 (73%) • Describes data sources and collection methods 17 (65%) • Describes how the plan progress will be reviewed 21 (81%) • Describes feedback loops to identify corrective measures and financial adjustments 14 (54%) • Clearly describes the need for operational research 21 (81%) • Describes a mechanism to coordinate operational research 9 (35%) a The full list of results by Checklist criteria is provided in MQSUN+ (2020d); and high-level country briefs developed as part of this review are available at https://mqsunplus.path.org/resources/country-briefs-from-the-review-of-sun-country-national-nutrition-plans/. b The Checklist included 'achievable' as a national multisectoral nutrition plan characteristic, but because only the text of the each plan was analysed and this measure could not be assessed, it was not classified as a 'basic' characteristic. To contextualize our results, in the following section, we explore the key elements assessed in this review based on the SUN Checklist Areas alongside relevant literature. Area 1 highlight an area for improvement given the importance of capturing data related to target populations (Christian & Smith, 2018; Galloway, 2017) . Furthermore, though the majority of plans (over 60%) included at least some sex-disaggregated data or discussion of how gender norms and roles impact nutrition in the country, the level of detail varied, and no plans referenced conducting a gender assessment or analysis. Assessing gender differences and considerations in health policies and programmes is important to adequately address and target interventions (Ostlin et al., 2006; UN Women, 2018) . Also, given the multisectoral nature of these plans, conducting a comprehensive review of programmes by sector is key to shaping a plan's proposed priorities and actions. Insights from the 'fill the nutrient gap' assessment emphasize the importance of a systems approach to conducting a nutrition situation analysis to ascertain barriers and factors across different levels (Bose et al., 2019) . As indicated in Section 3, plans varied in terms of the number and variation of nutrition-related sectors discussed in the plan and the level of detail included. Though variation is expected given different country contexts, further consideration could be given as to whether the information included for a given country was the most relevant to that country's nutrition situation, or if gaps indicate issues with data availability/quality or other factors, such as the level of engagement of specific ministries and partners. The goals, objectives and actions of a plan represent the core foundation and body of a planning document. Each country's situation will have different priorities, which will be reflected in the planned actions and objectives of a national MSNP (Darnton-Hill et al., 1998) . As noted in the results, the majority of plans demonstrated a commitment to global recommendations related to reducing malnutrition Area 2 of the SUN Checklist focuses on overall factors to ensure inclusive development and high-level endorsement of a plan. Securing high-level political commitment and involvement is an important component of successful multisectoral coordination and action for nutrition (Acosta & Fanzo, 2012; Ayele et al., 2020; Heidkamp et al., 2021) . Even though all plans had an effective year within or before the review period, six of the plans (23%) had not yet been formally validated or endorsed by a high-level political body (as could be determined by the document). This was true even of some plans that were considered final and official documents. Literature over the past several decades has continuously pointed to the importance of high-level (e.g. executive branch) commitment and political will to facilitate cross-sectoral coordination and elevate nutrition publicly (Acosta & Fanzo, 2012; Darnton-Hill et al., 1998; Field, 1987) . Although it is unclear whether explicit high-level endorsement is required for multiple ministries and/or local governments to move forward with implementation, at the very least, it signals to all stakeholders-who may not be accustomed to collaborating in a multisectoral fashion-that they are expected to integrate the plan in their existing responsibilities. Other reviews have similarly found gaps across some country MSNPs in clearly documenting stakeholder involvement and commitment, which may impede accountability and buy-in for the plan (Nguyen et al., 2020; WHO, 2018) . The lengthy process for developing and formally adopting a national nutrition plan or strategy may be a limitation (Nguyen et al., 2020) . Previous literature has also indicated the critical role of advocacy and engagement to facilitate resource mobilization, prioritization and implementation (Darnton-Hill et al., 1998; Field, 1987; Lamstein et al., 2016; Ouedraogo et al., 2019; Pomeroy-Stevens et al., 2016) . In this review, although the majority of plans did include at least some advocacy-related actions at national and subnational levels to promote implementation, engage stakeholders, or mobilize resources, the level of details varied and were missing completely in nearly a quarter of the plans-indicating this as an area for further strengthening. Represented by Area 3 of the SUN Checklist, a clear financial framework for a national MSNP that includes costing of planned actions, an assessment of the financial gap, and a plan for financial tracking and disbursement is crucial to support operationalization. A sound financial framework was a core gap across most country plans in this review. Other literature has similarly found insufficiencies around funding, financial allocation and resource tracking for nutrition across countries (Acosta & Fanzo, 2012; Manorat et al., 2020; Sodjinou et al., 2014) . In this review, although more than half of the plans estimated plan costs, plans rarely estimated financial gaps between the cost of actions and existing financial resources, provided details on a finance-tracking mechanism or established criteria for prioritizing actions in the event of a budgetary shortfall. Another cross-country review of SUN country plans found that only four out of 58 reviewed plans included budget for resource tracking (Manorat et al., 2020) , which, in addition to our findings, indicates this as a potentially persistent gap that may continue beyond the planning documents. Literature has indicated a lack of financing-related data as a barrier (Lamstein et al., 2016) that may contribute to these factors. Our analysis found that financial gaps, when estimated, were universally significant-which is noteworthy given that sufficient funding is pivotal to the success of nutrition plans (Acosta & Fanzo, 2012; Lamstein et al., 2016) . Managing financing shortfalls of MSNPs has long been noted as a challenge (Berg, 1987) . This suggests that all plans will need to prioritize resource mobilization efforts, at both domestic and international levels, and determine a process to prioritize interventions, key populations and/or vulnerable groups (Acosta & Fanzo, 2012; Berg, 1987; Heidkamp et al., 2021) . Beyond mobilizing resources, the few reviewed plans that included prioritization approaches proposed varying methods: For example, one country costed out a scenario that would target the region with the highest burden of child stunting, whereas another proposed prioritizing certain interventions depending on their estimated impact on the specific types of malnutrition within each region. Given the ambitious and large number of actions proposed in each plan, having a process in place to define and support prioritization will likely prove crucial, particularly as the SUN Movement enters its third phase. Based on the varying levels of detail on disparities-particularly at subnational level-and vulnerable populations in the reviewed plans, some countries may be more primed to make these decisions than others. The importance of governance for effective multisectoral implementation has been emphasized since the onset of multisectoral nutrition action (Bump, 2018; Field, 1987; Kennedy & Fekadu, 2016) . Strong governance bodies are key to support cross-ministerial coordination for implementation, as well as effective monitoring and funding disbursements (Acosta & Fanzo, 2012 (Acosta & Fanzo, 2012; Nishida et al., 2002) . Beyond broader governance, a key gap across many of the reviewed plans was designating the responsible agencies and actors for the proposed actions (only half of the reviewed plans did so). Ensuring clearly defined roles and responsibilities for accountability and effective prioritization was indicated as one of five core elements for effectively 'translating plans into action' as part of the 17th International Congress of Nutrition (Nishida et al., 2002) . Although it may be that some countries choose to elaborate these elements within operational planning documents, gaps across the reviewed plans in these areas could potentially impede effective implementation, coordination and results. Most plans in this review acknowledged technical and governance/organizational capacity as a key factor in the plan success. Literature highlights gaps in capacity and human resource constraints-both regarding technical and functional capacities among both individuals and institutions-as a common barrier in the successful implementation of national MSNPs (Jerling et al., 2016; Lamstein et al., 2016; Marasini & Mugenyi, 2016; Meerman, 2008; Nishida et al., 2002; Pelletier et al., 2012) . Given that this is cited as a persistent challenge, exploration into the specific capacity gaps that exist and how to facilitate effective operationalization, funding and implementation of capacity-building efforts requires further attention. Lastly, Area 5 of the SUN Checklist highlights critical elements of monitoring, accountability, evaluation and learning. Planning and investment to facilitate systematic collection, monitoring and analysis of nutrition indicators (both direct and indirect) and data has been suggested to contribute to improved success in achieving nutrition targets (Acosta & Fanzo, 2012) . Importantly, whereas most plans in this review discussed M&E to at least some extent, just under half defined processes to identify corrective measures based on plan reviews and monitoring. Relatedly, a review of 58 SUN country plans found that only about a third included cost estimates for nutrition data and M&E sections and noted that few countries included costing for M&E functions, such as planning and coordination as well as information synthesis and decision-making (Manorat et al., 2020) . Ensuring mechanisms are in place to translate data analysis into evidence-based decision-making is key (Acosta & Fanzo, 2012; Darnton-Hill et al., 1998) , alongside governments' commitment to promoting datadriven accountability (Nutrition for Growth, 2019). Although this review illuminates key strengths and gaps related to the content of MSNPs, there are noted limitations to this analysis. As previously noted, this review only looked at the main MSNP planning document; supplemental and corresponding plans or policies were not reviewed, nor did reviewers have knowledge of the plan development process. The definition of basic characteristics was intended to prioritize key items that should be included in a main planning document; however, these components are subject to debate, and it is recognized that plan structure and content vary across countries. Therefore, for some countries, gaps identified in this review could be elaborated elsewhere. Also, for the purpose of this review, plans were classified as either having 'met' or 'not met' a basic characteristic, versus being classified across a spectrum, to ensure applicability across a range of country contexts and to limit additional subjectivity. It should also be noted that assessing the operationalization of these plans was beyond the scope of this review, and as such, the rel- Within the global effort to improve nutrition for all, governments' ownership and leadership in adopting national MSNPs are critical. Planning, financing and scaling up multisectoral nutrition interventions are today-more than ever-essential to protect hard-won gains in the fight against all forms of malnutrition and achievement across the Sustainable Development Goals. To this end, though this review demonstrated both strong attributes and areas for growth within SUN country MSNPs. further guidance on the multisectoral nutrition planning process could support more effective operationalization of these plans (MQSUN +, 2020a). The findings from this review provide an important foundation to inform areas for further research and where additional such guidance may be beneficial. For instance, further exploration into key identified gaps around risk mitigation and emergency planning, financial analysis and detailed operational planning will be critical. The findings can also serve as an important baseline through which to consider progress in multisectoral nutrition planning across countries. More broadly, although this review cannot comment on the success and impact of the plans reviewed in reducing malnutrition and establishing a robust enabling environment for nutrition, previous literature has suggested an association between the existence of national MSNPs-and other evidence of institutional commitment to nutrition-and nutrition outcomes (Fracassi et al., 2020; Sunguya et al., 2014) . For example, after the development of their multisectoral nutrition strategic plan, Burkina Faso continued efforts towards operationalization, which led to the creation of a nutrition budget line and the establishment of a nutrition technical secretariat to lead nutrition implementation (Ouedraogo et al., 2019) . In Nepal, their MSNP led to improvements in the coordination, advocacy and sustainable structures for nutrition action . Though such achievements are not universal across countries, and both countries may still face certain barriers, this positive progress demonstrates the potential importance of having an MSNP in place to accelerate efforts to reduce malnutrition. This review serves as a foundation for further research assessing to what extent the inclusion (or exclusion) of certain characteristics in a plan contributes to effective operationalization and impact of a plan-which is critical to further inform effective multisectoral nutrition planning. The review framework can also serve as a useful tool to consider and evaluate gaps in MSNP during plan development or at the mid-term of implementation to facilitate improvements, foster dialogue on gaps and support needs, or act as a mechanism to evaluate operational progress on addressing malnutrition based on the country's plan. Going forward and into a post-COVID-19 world, SUN countries' capacity to continue to develop, prioritize and implement national MSNPs in a cost-effective way will be vital. The findings from this analysis can be leveraged by current and future policymakers, technical assistance providers, and regional and global stakeholders to advance multisectoral nutrition planning, budgeting and implementation towards a conducive, enabling environment for improved nutrition. The data that support the findings of this study are available from the corresponding author upon reasonable request. Amanda Coile https://orcid.org/0000-0002-4898-4745 Jolene Wun https://orcid.org/0000-0002-1459-1388 Monica T. Kothari https://orcid.org/0000-0001-5945-1728 Carolyn Hemminger https://orcid.org/0000-0002-0911-4042 Fighting maternal and child malnutrition: Analysing the political and institutional determinants of delivering a national multisectoral response in six countries. 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