There has been a significant progress in food and nutrition policy development across Europe in the past two decades. Despite this progress, most countries in the European region have, nevertheless, not achieved nutrition and dietary goals (1). Overall, a number of developments in global policy, research and guidance have contributed continuously to strengthening and supporting the implementation of food and nutrition policies across the countries (2-6).
However, the implementation of the policies continues to be a major challenge due to lack of funds, political commitment and coordination. Hence, more support should be given to the implementation and evaluation of policies, and a shift towards stronger environmental approaches is needed (7).
Following the endorsement of the First Action Plan for Food and Nutrition Policy for the WHO European Region 2000–2005 (3), an intersectoral working group with representatives from health, agriculture, tourism, education, environment, economy, labour and social affairs, finance, as well as other governmental institutions, developed the Albanian Action Plan for Food and Nutrition 2003-2008 (AAPFN), signed by the Prime Minister in July 2003 (8). The adoption of the AAPFN 2003-2008 by the government provided the basis for political commitment and regulatory entry point for all public institutions to translate the policy into actions in the field of food and nutrition in Albania. However, there is little published evidence about this event. The AAPFN aimed at reducing the level of foodborne diseases, protecting and promoting health, and putting public health at the heart of food policy.
The purpose of this paper is to describe the progress that has been made in the implementation of the AAPFN since 2003 – what has been achieved and what remains to be done – to consider its impacts to date, and to identify strategic priorities/critical areas and priorities for Albania’s future policy on improving the food and nutrition situation in Albania.
The evaluation expert group applied an intersectoral participatory approach involving, in addition to the review of existing documents and data, qualitative and quantitative methods. The same methodology was applied as for the evaluation of the implementation of the Slovenian Food and Nutrition Policy 2005-2010 (ReNPPP 2005-10) (9).
The intersectoral expert group employed the quantitative method using a 9 question logical assessment matrix (Table 1), with nine evaluations grades (Table 2) (9), to measure the achievements of the individual (re-shaped) goals of the AAPFN 2003-2008
A nine question logical assessment matrix (9).
|Q 1: Has there been enough evidence produced to set priorities for the individual goal?|
|Q 2: Were appropriate measures proposed for the individual goal?|
|Q 3: Were proposed measures adopted?|
|Q 4: Were adopted measures implemented?|
|Q 5: Were social inequalities tackled by proposed measures?|
|Q 6: Was at least 50% of the target population reached by the measure?|
|Q 7: Were sufficient financial resources provided for the implementation?|
|Q 8: Were strategic aims of the FNAP in line with implementation goals?|
|Q 9: Were implementation activities in line with the individual goal?|
Criteria for evaluation (9).
|Considerable success (+)||(4.8-5)|
|Moderate success (+/0)||(3.8-4.2)|
|Little success (0)||(2.8-3.2)|
|Minimal success (0/-)||(1.8-2.2)|
|No success (-)||(1.2 and less)|
The National Institute of Public Health conducted the qualitative assessment exercising a tool (9) with 36 closed questions with open space to express opinions, for the interview of an interdisciplinary sample (9) of 68-key informants-persons operating in public health nutrition, food safety and food availability related subfields, from a wide range of pertinent institutions and stakeholders. In total, 60 interviews were carried out.
2.1 Data Analysis
The intersectoral expert group estimated the achievement of individual goals calculating the average score for each goal (9) of the AAPFN 2003-08, as per the abovementioned criteria.
The processing of 60 completed questionnaires used a specially designed database and translated the questions or fields in the questionnaire into 87 variables during the analysis. Statistical Package for Social Sciences (SPSS, version, 17.0) was used for the analysis of quantitative data, whereas most of the analysis concerning the qualitative information applied horizontal qualitative techniques.
The expert group prepared a detailed analysis of the assessments conducted, recommendations included. One large intersectoral group discussed and agreed upon the recommendations for the future nutrition policy in Albania.
The authors aggregated the findings of this process.
The ‘methodology’ workshop (9), including a training session on quantitative methodology, was held in October 2011. Workshops sharing results were held in March and July 2012.
The APFN 2003-2008 addressed a food safety pillar through the fulfilment of four (reshaped) goals and a nutrition pillar through the fulfilment of eleven (reshaped) goals (Table 3).
Estimation by pillars1.
|Research data available, with priorities Q1 (5.0)||Measures were Proposed Q2 (3.9)||Measures were Adopted Q3 (3.8)||Measures were Implemented Q4 (3.5)||Social inequalities were tackled by the measure Q5 (4.4)||At least 50% of the Target Population was reached by the||Sufficient financial Resources were Provided Q7 (3.4)||Goals are in line with The strategic aim of||Implemented Activities are in line with the goals Q9 (4.6)|
|FOOD SAFETY (3.8)||5.0||3.1||3.8||3.3||NA||NA||3.3||4.3||4.3|
|1. Harmonising the legislation with the EU (4.8)||5.0||4.5||5.0||4.5||NA||NA||4.5||5.0||5.0|
|2. The improvement of food safety control and the establishment of SS (3.6)||5.0||3.0||3.0||3.0||NA||NA||3.0||4.2||4.2|
|3. Strengthening food control laboratories (2.7)||5.0||2.5||2.0||1.8||NA||NA||1.8||3.0||3.0|
|4. Strengthening technical capacities (4.1)||5.0||2.5||4.0||3.8||NA||NA||4.0||5.0||5.0|
|1. The prevention of malnutrition among women: adolescence pregnancy lactation (4.1)||5.0||3.7||3.7||3.7||5.0||3.0||3.5||4.7||4.7|
|2. Preserving the tradition of breastfeeding, and timely initiation of complementary feeding (4.3)||5.0||4.3||4.1||3.1||4.9||3.9||4.0||5.0||5.0|
|3. The evaluation of the mode of nutrition (4.0)||5.0||5.0||4.0||3.1||2.6||2.9||3.3||5.0||5.0|
|4.The evaluation of the nutritional status of the population (4.9)||5.0||5.0||5.0||5.0||5.0||4.6||4.3||5.0||5.0|
|5. Determining main risk factors for nutrition-related diseases (4.3)||5.0||5.0||4.2||4.0||4.6||2.8||3.2||5.0||5.0|
|6. The eradication of iodine deficiency in the Albanian population (4.7)||5.0||5.0||5.0||4.9||4.9||4.1||3.9||4.9||4.9|
|7. Anaemia prevalence assessment and the prevention of IDA (4.0)||5.0||4.6||3.3||3.1||4.9||3.6||2.2||5.0||4.3|
|8. The improvement of oral health (3.8)||5.0||4.4||3.3||2.7||3.7||3.0||3.8||4.4||4.4|
|9.The establishment of a national network for M&E of the nutritional status of the population (4.2)||5.0||5.0||3.2||4.0||5.0||2.5||3.5||5.0||5.0|
|10. Managing the nutritional education, informing the population on a healthy nutrition and healthy lifestyle (3.7)||5.0||3.9||3.3||2.9||3.4||3.0||2.3||4.9||5.0|
|(i) The compilation of Recommendations for a healthy nutrition and healthy lifestyle (3.9)||5.0||4.3||3.7||2.7||4.0||3.3||2.3||5.0||5.0|
|(ii) The preparation of inter-sectorial promotional interventions (4.1)||5.0||4.1||3.7||3.7||4.1||3.9||3.1||4.7||5.0|
|(iii) Strengthening intellectual potential on nutrition (3.2)||5.0||3.2||2.6||2.4||2.0||1.8||1.6||5.0||5.0|
|11.The improvement of legislation for the improvement of a nutrition-related health status (4.7)||5.0||5.0||3.8||4.5||4.6||4.5||4.5||5.0||5.0|
Food security component was not addressed specifically compared to two other pillars of this Plan, namely: food safety and nutrition. Thus, it neither elaborates specific goals and measures nor does it identify the resources needed to implement any action related to food security. Regarding the adequacy and consistency of the way this policy document addresses food safety pillar, the evaluation showed the highest level of availability of evidence to set priorities for the respective goals, the food safety implementation goals aligned with strategic aims and the same as the implementation activities with the individual goals, but small appropriateness related to the measures proposed for the food safety individual goals.
The evaluation revealed that the food safety measures proposed by the Plan were adopted moderately, and that the food safety measures adopted were implemented partially successfully. The financial resources for their implementation, quantified through perceptions of key informants, were evaluated as partially sufficient.
With regard to the implementation of food safety individual goals, the evaluation revealed that ‘the improvement and harmonization of food safety legislation with the European Union’ was implemented successfully; moreover, ‘strengthening food safety technical staff capacities at the central and regional level’ was implemented moderately successfully; in addition, ‘the improvement of food safety control system and the establishment of a surveillance system’ was implemented partially successfully, whereas the goal of ‘strengthening and increasing the level of food control laboratories, in health, agriculture and food systems’ was implemented very partially successfully.
The evaluation found the overall implementation of the food safety strategic goals of the AAPFN 2003-08 moderately successful (Table 4).
Findings from the logical evaluation matrix2.
|The number of goals||4||11|
|1||No success (%)||0||0|
|2||Minimal/no success (%)||0||0|
Regarding the adequacy and consistency of the way the AAPFN 2003-08 documents address nutrition pillar, the evaluation found a very high level of the availability of evidence to set priorities for relative goals, nutrition implementation goals very aligned with strategic aims and the same as the implementation activities with the individual goals. The evaluation revealed that the measures for nutrition individual goals were appropriately proposed, and that social inequalities were tackled by them sufficiently. The evaluation revealed that the nutrition measures proposed by the Plan were adopted moderately, that the nutrition measures adopted were partially implemented, that the coverage by them of at least 50% of target population was partially achieved, and that the financial resources provided for their implementation were partially sufficient.
With regard to the implementation of nutrition individual goals, the evaluation revealed that ‘the evaluation of the nutritional status of the population” was likely to be implemented very successfully, whereas the goals of ‘preserving the tradition of breastfeeding, exclusive breastfeeding and providing timely initiation of complementary feeding, ‘determining main risk factors for nutrition-related diseases, ‘the eradication of iodine deficiency in the Albanian population,’ and ‘the improvement and strengthening of legislation for the improvement of health status due to a better nutrition’ were considered to be implemented successfully.
‘Managing the nutritional education, informing the population on a healthy nutrition and healthy lifestyle’ was estimated to be implemented partially successfully. The evaluation found the overall strategic nutrition goals of the AAPFN 2003-08 implemented ‘moderately’ successfully (Table 4).
Regarding knowledge sharing process of the AAPFN 2003-08 after its adoption, only 55% of key informants interviewed had a good or relatively good knowledge about the APFN and, among them, the majority worked in central institutions and came from the health sector, compared to agriculture, education, culture, tourism, youth, sport, work, social welfare, finances and civic society sectors, producers and private enterprises. The lack of the systematic exchange of information among different management levels within a sector and among different sectors was identified as the main cause of not having enough knowledge on the Plan.
Regarding the extent of the influence the AAPFN had on improving the situation, respondents thought that the Plan had contributed more to the increased consumption of fruits and vegetables than to the reduction of food-borne diseases and obesity.
There seemed to be an almost complete consensus among key informants interviewed regarding the successfulness of the implementation of three main nutrition goals, namely: (i) support and promotion of breastfeeding; (ii) established health education programs for pregnant and postpartum women, and (iii) improved availability of health beneficial foods and healthy nutrition.
The main types of implemented actions mentioned by key informants included informing and educating the media, consumers, whole population, mothers, school-aged children, teaching staff, private enterprises for specific issues (such as iodized salt) and health professionals in particular; the enlargement of the network of baby-friendly maternity-hospitals; the development of Albanian Guidelines for a Healthy Nutrition; population nutritional status monitoring with the focus on the childbearing-age of women and children; preparing bylaws and improving legislation in the field of food and nutrition along with the harmonization of the respective legislation with the EU framework; food safety capacity building and food safety inspection and monitoring activities.
Regarding the employment of the participatory multisectoral approach during the implementation of AAPFN activities, the respondents from the Ministry of Health and Ministry of Agriculture, Food and Consumer Protection, in 72% and 63%, respectively, declared that they, in general, frequently collaborate with other ministries. This collaboration is likely to be more between these two ministries than between each of them and others. There seem to be somehow more positive opinions related to the level of collaboration with the Ministry of Education and Science, while regarding other ministries, according to key informants, there seems to be consistently scarce or absent collaboration. Collaboration with the Ministry of Finance and the Ministry of Culture, Tourism, Youth and Sports is reported to be at very low levels.
Regarding other institutions, the respondents’ collaboration is likely to be better with the public health authorities, media, NGOs, health centres and education institutions, and less frequent with professional institutions, faculties, food industries, while respondents report that their collaboration with chambers of commerce is insignificant. A significant number of respondents think that the AAPFN has not been very effective in supporting the communication, especially with the public and other actors outside the public system (target groups, civil society organisations, etc.). It seems that the plan had been mostly effective in facilitating communication among professionals from the same sector.
Difficulties or barriers encountered during the implementation of the Plan, identified by a large number of respondents, were related to:
- Designing the plan: Most of the objectives of the plan were relatively clear and feasible, but detailed descriptions of the actions, the responsible actors, implementers and the time frame were often missing; in some cases, objectives and measures were very general and not measurable; estimated costs for the implementation and prioritisation of actions were missing too; the plan was also lacking an integrated plan for monitoring and the evaluation of the effectiveness of proposed objectives and activities.
- Time and energy was lost due to frictions among different sectors and institutions.
- There was a shortage of institutional and infrastructural support, in particular, there was lack of a national body responsible for the implementation and coordination of activities of the nutrition policy and insufficient capacities and ‘know how’ at the central and local level.
- There were difficulties related to the population’s nutrition habits and resistance to behavioural changes.
Among factors which could help the implementation of food and nutrition policies, the key informants consider: firstly, the awareness of professionals and the public; secondly, the collaboration with other sectors; and thirdly, financial support.
The prioritised recommendations/actions for the future nutrition policy in Albania, according to the key informants, were as follows:
- Exercising regular inspection measures over the energy and nutritional value of school and nursery school meals.
- Integrating healthy nutrition-related topics into school curricula.
- Installing water fountains in schools and nursery schools.
- Integrating measures in the field of nutrition with measures in the field of physical activity.
- The establishment of a cross-sector body in the field of food supply/food safety/nutrition.
- The preparation of specific measures to limit the trend of obesity.
- Increasing the encouragement of farmers to sell food in the local environment.
- Restricting the marketing of unhealthy foods to children.
- Supporting measures to improve the diet of socially disadvantaged groups.
- Reducing the taxation of fruits and vegetables.
The AAPFN 2003-08 was the main strategic policy, providing the basis for political commitment, and enabling public health and non-health institutions to transfer policy into action in the fields of food and nutrition in Albania. This Plan created and supported a policy environment that placed more emphasis on food safety and nutrition than on food security. In this sense, the Plan provides only a vague guidance for integrating some aspects of food security in developmental programs, while it does not point out activities at the macro and specific level for respective sectors and institutions. There is a lack of actions addressing the macro environment (food supply sector, urban planning and transport) through accessibility, affordability and availability.
Despite the overall progress over the last decade in improving the food and nutrition situation, legal and institutional frameworks, research and evaluation activities, and public awareness, Albania is still facing multiple nutrition-related problems. Albania is currently facing the double burden of malnutrition, including high rates of stunting (19 %) and overweight among children under 5 years (22%), disparities in health and nutrition status and micronutrient deficiencies (10), and a burden of Non Communicable Diseases (NCD) with an increasing trend (11). A current analysis revealed that actions were not being implemented on a regular basis and nationally, and that they were not tailored to the current dynamics of the food system (price, availability and accessibility of food) and marketing pressure that addresses the demand for food in a completely different direction from what the dietary guidelines indicate (7). This cannot be achieved by the health sector on its own; it requires the involvement of different sectors of the government as well as different stakeholders in the society (12). The AAPFN 2003-08 did not create a supportive environment to facilitate the fulfilment of health and nutrition objectives with the contribution of all sectors. The information on the implementation and effectiveness of specific interventions of the AAPFN 2003-08 was not available. The analysis showed that the document includes neither detailed implementation plans and respective financial implications nor mechanisms and tools to evaluate the implementation.
Regardless of the engagement of different stakeholders in the APFN 2003-08 formulation, the lack of effective collaboration among different sectors and institutions acted as a barrier for the implementation of this plan. The APFN 2003-08 did not clearly define the responsible ministries and task performers, which could support the implementation of actions, and it did not explicitly foresee the establishment of any specific administrative structure/body responsible for the implementation and coordination of activities of this food and nutrition policy. The presence of a national coordination body, such as a food and nutrition council, allows governments to develop, implement, monitor and evaluate nutrition policies, guidelines and action plans (7).
The evaluation methodology (9) used in Albania, helped us to show a similar multifaceted nature of the food and nutrition as in Slovenia, where the methodology was developed. So, the key common findings were the need for (i) an intersectoral response, involving the design and implementation of food and nutrition policies; (ii) systematically including evaluation and monitoring mechanisms and tools in the policy document; (iii) having in place a food and nutrition policy intending to achieve its primary objectives through influencing other public policy measures.
4.1 Study Limitations
This analysis was limited to the AAPFN 2003-2008 document and interviewing of 68 key informants, and additional information obtained from recent publications, various web-sites of national health ministries and health agencies. Although the sample of key informants had a multisectoral representation centrally and locally, it remains a purposive sample that does not allow extrapolating the findings on knowledge over the AAPFN 2003-2008 in all relevant executives and professionals in the country. However, the main purpose of the assessment was to help analyse the appropriateness of the plan designation and gaps or weaknesses during its implementation through a multisectoral participatory identification of key deficiencies and relevant actions to address them.
The comprehensive, participatory assessment of the Action Plan for Food and Nutrition (APFN) 2003-2008 created an evidence base for the development of the new food and nutrition policy more responsive to food and nutrition situation in Albania. The institutional intersectoral response to the multifaceted nature of a double burden of malnutrition is essential to improve nutritional wellbeing and health outcomes in Albania.
The main lesson drawn from this process was that ‘policy makers should develop implementation strategies that explicitly take account of financial, managerial and technical aspects of the policy (capacity) and the anticipated resistance and support from all the actors in the subsystem within and outside government, to avoid the gap between policy expectation and reality’ (13).
Albania case study has shown that in spite of a very demanding evaluation of the national policy, the methodology used in this study (9) can be transposed from one country (Slovenia) to another (Albania). It has the ‘potential’ to be used to evaluate the implementation of other public policies in other contexts and sectors with some respective adaptations. Therefore, this study is a contribution to future endeavours to advance the methodologies for the evaluation of the implementation of complex national policies.
This evaluation was performed in the framework of the Joint Programme on Nutrition 2010-2013, funded by the Spanish Millennium Development Goals Achievement Fund and implemented by the Albania Ministry of Health (MoH) and Ministry of Agriculture, Food and Consumer Protection (MoAFCP), with support from the World Health Organisation (WHO), the United Nations Children’s Fund (UNICEF) and the Food and Agriculture Organisation of the United Nations (FAO). The preparation of this paper was not financially supported.
A verbal informed consent from the Directory of Public Health at the Albania Ministry of Health allowed us to conduct the assessment in question with an intersectoral working group, consisting of representatives from the Ministry of Health and Ministry of Agriculture, Food and Consumer Protection, while the WHO provided technical assistance with the assessment methodology.
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