**Background:** Burkina Faso, a low-income land-locked Sahelian country, faced persistent malnutrition driven by poverty, rainfall variability, poor water management, and rapid population growth. Despite these challenges, under-five stunting declined substantially from a peak of 45% in 1998/99 to 25% in 2018. This study aimed to identify macro-level factors—actors, ideas, policies, and capacities—that created an enabling environment for nutrition progress.
**Methods:** The study used a mixed-methods 'stories of change' approach. Data sources included: (1) a stakeholder influence mapping exercise using the Net-Map methodology with 20 participants (government, UN, donors, NGOs, civil society) conducted in July 2018; (2) semi-structured in-depth interviews with 20 national-level key informants (10 nutrition experts, 10 food security experts) with an average of 22 years of experience, conducted between September 2018 and February 2019; (3) 12 provincial-level interviews in two regions selected for significant stunting reduction; (4) a policy timeline reviewing 43 policy documents with nutrition objectives, indicators, or budgets; and (5) supplementary document analysis. Triangulation was organized using a framework covering leadership/stakeholders, ideas/framing/evidence, institutions/policy/coherence/accountability, and capacity/resources/financial commitments.
**Key Results:** Four major factors drove nutrition progress. First, the Ministry of Health (MOH) provided strong leadership: nutrition was officially housed in the MOH in 2002 with the creation of the Directorate of Nutrition (DN), which acted as a focal point for coordination. The National Council on Nutrition Consultation (CNCN) was created in 2008, and the Technical Secretariat for Food and Nutrition (STAN) in 2018. Pivotal moments included the first nutrition-specific policy in 2007, joining the Scaling Up Nutrition (SUN) movement in 2011, and the first IYCF action plan in 2013. Second, cooperation between nutrition actors—particularly the DN and the informal group of technical and financial partners (PTF-Nut)—was effective in mobilizing funding and defining coherent nutrition objectives. Horizontal coordination primarily involved health and agriculture sectors, though the CNCN was criticized for low member involvement and lack of accountability. Third, successful programs included salt iodization, micronutrient supplementation, management of acute malnutrition, market gardening, 'baby-friendly' hospitals, and nutrition surveys. Fourth, financing increased from both external donors and the national budget, though the majority continued to come from international sources. Persistent challenges included inadequate training of MOH staff, insufficient funding at decentralized levels, weak vertical coordination, and a lack of accountability culture. National experts noted that evidence linking WASH and education to nutrition outcomes remained insufficient.
**Clinical Implications:** Burkina Faso's experience demonstrates that sustained political commitment anchored in a lead ministry, combined with effective coordination mechanisms and multisectoral collaboration—especially with agriculture—can drive substantial reductions in child stunting even in resource-limited settings. The findings highlight the need to: (1) anchor nutrition coordination at supra-ministerial levels to improve multisectoral engagement (a new framework adopted in July 2021 moved in this direction); (2) increase domestic budget allocation for nutrition to reduce dependence on external donors; (3) empower decentralized bodies with funding and decision-making authority; (4) strengthen accountability mechanisms at all levels; and (5) integrate nutrition objectives into communal development plans. Emerging threats from climate change, insecurity, and the rising availability of non-nutritious foods require proactive policy responses. The study underscores that nutrition improvement results from concurrent progress across multiple sectors—health, agriculture, WASH, education, and social protection—rather than from any single intervention.