Abstract

Background: Advanced hunger and all forms of malnutrition have led to a growing interest in a favorable environment for nutrition around the world. In response to the challenge of nutrition, west Africa countries like Côte d'Ivoire has demonstrated its commitment by establishing policies and the development of infrastructures that promote favorable environment for nutrition. Nevertheless, these policy documents are not well known and shared. Thus, objectives of this study are to collect and to classify all policy documents and actions implemented in Côte d'Ivoire promoting sustainable and healthy food environments. Methods: Data collections were done online and physically thanks to the collaboration of Governmental and non-governmental institutions from food environments. Documents were classified according to their framework origins (e.g., policy, strategic, and operational) and the Food-EPI tool. Food-EPI tool is composed of two modules of good practice indicators which are the 'policies' module and the 'infrastructure support' module. Results: In total, 113 documents were collected for the period of 1969 to 2022. Fifty-four documents inform on the 'policies' module, while fifty-nine documents provide information on the 'infrastructure support' module. Fifty-four percent of the collected documents come from the operational framework, 25% from the policy framework and 21% from the strategic framework. Conclusion: This study demonstrated that since independence in the 1960s the government of Côte d’Ivoire has had an ongoing interest in the food environment and nutrition. Moreover, thanks to the classification of the 113 policy documents collected with Food-EPI tool, it will be possible to evaluate for this country many good practice indicators promoting sustainable and healthy food environment.

1. Introduction

Global urbanization, agricultural industrialization, population growth, climate change, and technological advancements have significantly impacted food systems worldwide. This influence is particularly notable in Africa ¹, where it has led to drastic changes in food systems, triggering a nutritional transition across the continent ¹.

During the process of nutrition transition, alterations take place within the food supply causing a shift from diets primarily founded on cooking fresh or minimally processed food to diets characterised by elevated consumption of processed and ultra-processed food products having high amounts of sugar, salt, and fat, as well as food additives ^{1, 2}. This dietary adjustment has caused a rise in the general prevalence of overweight, obesity, and non-communicable diseases (NCDs) related to diet in Africa ¹.

Côte d'Ivoire suffers from the triple burden of malnutrition marked by the persistence of undernutrition resulting from chronic and acute malnutrition and deficiencies in essential vitamins and micronutrients as well as the accentuation of overnutrition ³. In Côte d'Ivoire, a total of 3,395,450 individuals are facing food insecurity while 36,000 individuals are in emergency situations ⁴.

Despite this, the Ivorian Constitution's Article 19 has recognised "the right to a healthy environment" for all since 2016. Furthermore, Article 28 states that it is the community's and each person's duty, whether natural or legal, to protect the environment and promote quality of life.

Moreover, nutrition is not solely a matter of health, food security, consumption, or social progress. Rather, it constitutes a significant aspect of the development of communities and nations, and hence, requires investment ⁵. To achieve good nutrition, policies must be developed and supported with sufficient strength to foster positive impacts on food environments. It also involves establishing infrastructures capable of supporting and facilitating the implementation of the developed policies.

The Ivoirian government has established policies and infrastructure aimed at enhancing the populace's quality of life. These comprise the National Agricultural Investment program (PNIA 1&2), the National Nutrition Policy ⁶, and the National Multisectoral Nutrition Plan ⁷.

Nevertheless, few studies have comprehensively encompassed all food environment-related policies and infrastructure in the country. The limited number of studies available typically pertains to a particular sector of government.

The study was initiated in Senegal by the Research Network on Public Policies and Food Systems in West Africa (REPSAO). Then, it was conducted in four others French-speaking West African nations (Benin, Burkina Faso, Côte d'Ivoire and Togo), was initiated by the REPSAO. The International Development Research Centre (IDRC) is supporting the study. In Côte d'Ivoire, the study was conducted with the collaboration of the Executive Secretariat of the National Council for Nutrition, Food and Early Childhood development (SE-CONNAPE).

The main objective of this study is to provide a comprehensive overview of the policies and measures implemented by the government of Côte d'Ivoire towards establishing healthful and sustainable food systems. Specifically, this involved making an inventory of policy and infrastructure documents related to food environments in Côte d'Ivoire and structuring the various documents collected according to framework and orientation.

2. Materials and Methods

This study took place in Côte d'Ivoire in collaboration with CONNAPE, government institutions, research programs, UN organizations, universities, and civil society.

The tool used for this study is the Food-EPI (Healthy Food Environment Policy Index), which monitors and evaluates public sector policies and actions to create healthy food environments ⁸.

Food-EPI is one of the modules of the INFORMAS network created by an international group of independent public health experts and representatives of medical associations and non-governmental organizations. INFORMAS aims to complement World Health Organization (WHO) surveillance efforts, such as the Global NCD Monitoring Framework, which has not focused on the food environment and policy indicators. The Food-EPI module is implemented in more than 20 countries around the world including Africa, notably in Kenya, Uganda, Ghana and Senegal ⁹. Our study used the Food-EPI process to collect data in Côte d'Ivoire.

The Food-EPI tool (Figure 1) includes a "policy" component with domains that address specific aspects of food environments and an "infrastructure support" component with domains that strengthen systems to prevent obesity and non-communicable diseases (NCDs). The good practice indicators contained in these areas encompass the policies and infrastructure support needed to improve the safety of food environments in order to prevent obesity and diet-related NCDs ⁸.

However, the Food-EPI tool focused primarily on food environment actions related to the prevention of obesity and diet-related NCDs ⁸.

Food-EPI has been implemented in a few sub-Saharan countries, including Ghana, Kenya and Senegal ^{10, 11}. Following this, a key recommendation from stakeholders involved in the Food-EPI process in these countries is to make Food-EPI indicators sensitive to the creation of healthy food environments to combat undernutrition, as they are a major public health problem in the sub-Saharan African region ¹². It is in this context that a team from INFORMAS and researchers involved in research on food environments began a three-stage process in 2020 (gathering evidence, selecting the most relevant indicators and identifying specific areas of the Food- EPI tool to integrate them) aimed at developing relevant indicators of undernourishment, to be included in the Food-EPI tool. As a result, 12 new priority indicators have been selected, relating to the double impact actions recommended by the WHO on breastfeeding and complementary feeding, marketing regulations, national policies to combat overweight, NCDs and undernutrition, health systems (growth monitoring) ¹³. In addition, indicators on hygiene, water and sanitation (WASH), food retailers and traders (hygiene and sanitation) and health safety (microbial and chemical contamination) have been added.

The methodology used in this study is the INFORMAS methodology of the Food-EPI Tool. This methodology, together with a declaration of conflict of interest, was submitted to the National Ethics Committee for Health and Life Sciences (CNESVS) of the Côte d'Ivoire Ministry of Health and Public Hygiene. The Food-EPI process allowed us to collect the data and collate them into an evidence document ^{8, 14}.

Sharing the Food-EPI project at a national level and involving a multisectoral range of stakeholders were critical components in conducting the study of Côte d'Ivoire. The Food EPI vision was shared with stakeholders using CONNAPE (National Council for Nutrition, Food, and Early Childhood development), which facilitated the engagement of various nutrition-related structures and stakeholders.

Following the example of holding meetings between the research team and their respective institutions to share the tool, a meeting was organised at the CONNAPE Executive Secretariat to bring together various stakeholders.

In addition, the sharing of Food-EPI entailed cooperation among University Félix Houphouët-Boigny (UFHB) for administrative and financial management, CONNAPE, and the Ministry of Health, Public Hygiene, and Universal Health Coverage for ethical considerations in the study.

This phase entailed the gathering of documents from different institutions to retrieve data on public nutrition policies, budgetary details, and governmental activities associated with the food environment in Côte d'Ivoire. The documents were procured physically by resource persons assigned by their respective institutions, or online, through their institution's webpage or via a Google search. The analysis of the data obtained culminated in the creation of an evidence-based document.

3. Results

A total of 113 documents relating to food environments in Côte d'Ivoire were collected during this study. Each document was linked to one or more indicators of good practice in the Food-EPI tool (Table 1) and then structured by policy, strategic and operational framework.

Of the 113 documents collected, 54 are divided into the seven (7) areas of the "Policy" component and 59 into the six (6) areas of the "Infrastructure Support" component.

The documents collected were classified according to three frameworks: political, strategic and operational (Figure 2). Of these frameworks, the operational framework contained the greatest number of documents (61 out of 113) and the strategic framework the fewest (24 out of 113).

Documents collected and classified within the policy framework represent 25% (28 out of 113). They are made up of laws, decrees, ministerial and interministerial orders, policies and other types of documents (Table 2). The number of documents at each sub-level of the policy framework is shown in Figure 3.

There are less policy framework documents (Table 3) in comparison to strategic framework documents (24 out of 113). These consist of national multisectoral and sectoral plans classified under the "plans" sub-level, together with national strategies and other documents. Among these, the majority are classified under the "strategies" sub-level, amounting to 13 documents (Figure 4).

Surveys, evaluation and analysis studies, study and activity reports, national guides and guidelines were presented in the operational framework, which contains the largest number of documents, with 61 (Table 4). Figure 5 shows the number of documents for each sub-level.

4. Discussion

After collecting documents for the Food-EPI project in Côte d'Ivoire, we compiled a list of 113 policy and action documents related to food environments. This exceeds the number collected by Manga et al. in Senegal in 2019 (47 documents), indicating the efforts of the Ivorian government to enhance food environments.

Structuring documents according to different areas of the Food-EPI tool revealed that the "infrastructure support" component received more documents than the "policies" component. This may be due to the fact that, although the first component has fewer areas than the other, it has more good practice indicators (31 compared to 28). Additionally, the execution of a policy or Program necessitates various infrastructure that span across multiple sectors of activity ¹⁵.

Classifying them into three levels – policy, strategic, and operational frameworks – the descending order of document count is as follows: operational framework ˂ policy framework ˂ strategic framework. This ranking order was also discovered by Manga et al. ¹⁰. The Ivoirian government has established a policy framework, which consists of national policies and regulations. The accompanying sectoral policies are presented in the strategic framework. Furthermore, the operational framework encompasses documents that specify the activities required for policy implementation.

It is worth noting that a single policy or plan may produce multiple operational documents. This text adheres to the principles of academic writing quality and lacks context. Therefore, it does not require any improvement.

In regards to the policy framework, four sub-levels have been identified in the following order: policies are inferior to decrees, orders are superior to decrees, and finally, laws are superior to orders. While many decrees are typically issued following orders, there are also instances where they are issued directly by the President of the Republic, without an order to serve as their source.

The arrangement of the strategic framework documents was led by the titles of the collected documents. Some of the documents are titled "national plans or sectoral plans", while others are labelled as "national strategies or sectoral strategies" or "strategy plans...".

The majority of the documents collected, amounting to 54%, fall under the operational framework, which consists of practical nutrition guides, surveys, activity and policy reports, and other studies related to food environments. The prevalence of records in this category could be clarified by the fact that activity reports are accessible to the general public. This is not automatically valid for documents categorized under the other two frameworks. Furthermore, a strategy or policy may generate multiple activity reports.

Moreover, additional examination has demonstrated that the documents accumulated belong to various government ministries. This could reflect the multisectoral aspect of nutrition in Côte d'Ivoire, an approach which has the potential to significantly bolster the fight against malnutrition. Nevertheless, the Ministry of Health and Public Hygiene (MSHP) and the Prime Minister's Office are the primary institutions responsible for these documents.

According to the roadmap ¹⁶, the MSHP is one of the governmental sectors in which nutrition has been defined. Within this Ministry, there are coordinating bodies such as the National Nutrition Program (PNN), the National Program for the Prevention of Non-Communicable Diseases (PNPMNT) and the National Mother and Child Health Program (PNSME), which have direct or indirect missions to enhance the nutritional status of the Ivorian populace. Regarding the significant number of documents obtained from the Prime Minister's Office in the compiled batch, this may be due to the significant role of nutrition in Côte d'Ivoire, which is strategically positioned under the National Nutrition Council and subsequently under CONNAPE directly under the Prime Minister's Office.

The study's collected documents in Côte d'Ivoire span from 1969 as the earliest to 2022 as the most recent. This indicates that since gaining independence in 1960, the government of Côte d'Ivoire has been consistently committed to addressing the matter of nutrition, specifically the food security of its citizens.

5. Conclusion

The objective of this study was to provide a comprehensive list of policies concerning food environments implemented by the government of Côte d'Ivoire. The study identified a number of policies and infrastructure developments related to food environments in Côte d'Ivoire. These policies and infrastructure demonstrate the interest expressed by the State of Côte d'Ivoire in the field of nutrition and food environments in general. However, assessing the degree to which these policies have been implemented would enable one to determine Côte d'Ivoire's position with regards to the standard of food environments.

ACKNOWLEDGEMENTS

This study was funded by the International Development Research Centre (IDRC). To this end, The Food-EPI Côte d'Ivoire research team would like to thank the IDRC. It also thanks the Conseil National pour la Nutrition, l'Alimentation et le développement de la Petite Enfance (CONNAPE) for technical and logistical support during data collection, and expresses its gratitude to government institutions, teaching and research institutions, civil society organisations and United Nations organisations.

List of Abbreviations

Abreviations Meanings

CNESVS National Ethics Committee for Life Sciences and Health

Food-EPI Food Environment Policy Index

INFORMAS International Network for Food and Obesity / Non-communicable Diseases (NCDs) Research, Monitoring and Action Support IRDCInternational Development Research Centre

MSHP Ministry of Health and Public Hygiene

NCDs (Non-Communicable Diseases)

PMNDPE Multisectoral Nutrition and Early Childhood Development Project

PNMIN National Multisectoral Nutrition Information Platform

PNN National Nutrition Programme

PNPMNT National Program for the Prevention of Non-Communicable Diseases

PNSME National Mother and Child Health Programme

SE-CONNAPE Executive Secretariat of the National Council for Nutrition, Food and Early Childhood Development

UFHB Félix Houphouët-Boigny University

References