Accelerating Nutrition Improvements in sub-saharan Africa (ANI) Report of the baseline and end-line perception surveys in ten countries

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1 Accelerating Nutrition Improvements in sub-saharan Africa (ANI) Report of the baseline and end-line perception surveys in ten countries

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3 Accelerating Nutrition Improvements in sub-saharan Africa (ANI) Report of the baseline and end-line perception surveys in ten countries

4 Accelerating nutrition improvements in sub-saharan Africa (ANI): report of the baseline and end-line perception surveys in ten countries ISBN World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Accelerating nutrition improvements in sub-saharan Africa (ANI): report of the baseline and endline perception surveys in ten countries. Geneva: World Health Organization; Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at Sales, rights and licensing. To purchase WHO publications, see To submit requests for commercial use and queries on rights and licensing, see Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Edited by Cathy Wolfheim Design and layout by Sue Hobbs Printed in Switzerland

5 Contents Acknowledgements Abbreviations Executive Summary I. Introduction 1 II. Methods 2 Survey tools 2 Timing of surveys 2 Implementation of surveys in countries 3 Global level analyses 3 Assessment of the ANI PMF indicators 3 PMF Intermediate outcome 1300: Awareness of the country s nutrition situation 3 PMF Immediate outcome 1120: Government capacity for nutrition surveillance 3 PMF Immediate outcome 1220: Health workers capacity to deliver nutrition interventions 5 PMF Intermediate outcome 1100: Health workers capacity and confidence to do nutrition surveillance 5 III. Results 6 Responses 6 Perception of the nutrition situation and priorities in countries 6 Awareness of Global Nutrition Target-related problems in countries 6 Awareness of nutrition problems and causes beyond the Global Nutrition Targets 8 Government priority for nutrition 15 Perception of nutrition surveillance 17 Government capacity for nutrition surveillance 17 Nutrition data being collected 20 Use of nutrition data 20 Perception of health worker capacity for delivering nutrition services and performing nutrition surveillance 20 Health workers capacity to deliver nutrition interventions 20 Health worker training 24 Health workers capacity and confidence to do nutrition surveillance 26 Summary of survey results 27 IV. Discussion and conclusion 29 V. References 30 vii viii iv REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES iii

6 List of Tables Table 1. Questionnaire tools, target groups and recommended sample sizes per country 2 Table 2. Country data related to the 2025 Global Nutrition Targets: prevalence and year 4 Table 3. Cut-off values used to determine country-relevant nutrition problems 5 Table 4. Number of respondents by respondent group 7 Table 5. Summary of baseline and end-line values for ANI PMF perception indicators 28 ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) List of Figures Figure 1. Indicator 1300: Awareness of a majority of country-relevant problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) 8 Figure 2. Problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) 9 Figure 3. Problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by type of respondent (n= 450 at baseline, 298 at end-line) 10 Figure 4. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development practitioners and media (n= 450 at baseline, 298 at end-line) 11 Figure 5. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) 12 Figure 6. Causes of nutrition problems as perceived by respondents representing government at national and district level, development practitioners and media (n= 450 at baseline, 298 at end-line) 13 Figure 7. Causes of nutrition problems as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) 14 Figure 8. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line (n=767 at baseline, 167 at end-line) 15 Figure 9. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line, by country (n=767 at baseline, 167 at end-line) 16 Figure 10. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line, by type of respondent (n=767 at baseline, 167 at end-line) 16 Figure 11. Health workers perception of priority given to nutrition by decision-makers and by themselves in their daily work in ten countries at baseline and in three countries at end-line (n=317 at baseline, 61 at end-line) 17 iv

7 Figure 12. Indicator 1120: Perceived high or very high government capacity for nutrition surveillance as reported by respondents representing government at national and district level and development practitioners, by country (n=395 at baseline, 298 at end-line) 17 Figure 13. Government capacity for nutrition surveillance as perceived by respondents representing government at national and district level and development practitioners, by country (n=395 at baseline, 298 at end-line) 18 Figure 14. Government capacity for nutrition surveillance as perceived by respondents representing government at national and district level and development practitioners, by type of respondent (n=395 at baseline, 298 at end-line) 19 Figure 15. Government capacity for various aspects of nutrition surveillance as perceived by respondents representing government at national and district level and development practitioners (n=395 at baseline,298 at end-line) 19 Figure 16. Collection of Global Nutrition Target indicators as reported by government respondents at national and district levels and health workers (n=615) 20 Figure 17. Collection of 2025 Global Nutrition Target indicators as reported by government at national and district levels and health workers, by country (n=615) 21 Figure 18. Uses of nutrition data collected as reported by government respondents at national and district levels (n=298) 21 Figure 19. Perception of nutrition information as reported by media respondents (n=55) 22 Figure 20. Indicator 1220: Correct knowledge on at least six out of eight questions related to the delivery of nutrition services among health workers in the three scale-up countries, by country (n=115 at baseline, 79 at end-line) 22 Figure 21. Correct knowledge on delivery of various nutrition services, as reported health workers in the three scale-up countries, by country (n=115 at baseline, 79 at end-line) 23 Figure 22. Training and perceived training needs among health workers in ten countries at baseline (n=317) 24 Figure 23. Health worker knowledge of and confidence to carry out IYCF intervention in ten countries at baseline, by breastfeeding training status (n=317) 25 Figure 24. Health worker knowledge of and confidence to manage SAM in ten countries at baseline, by SAM management training status (n=317) 26 Figure 25. Indicator 1100: Confidence in most or every aspect of implementing four nutrition surveillance activities as perceived by health workers in ten countries, by country (n=317) 26 Figure 26. Confidence in implementing four nutrition surveillance activities as perceived by health workers in ten countries, by nutrition surveillance training status (n=317) 27 Figure 27. Health worker knowledge about WHO Growth Standards in ten ANI countries, by nutrition surveillance training status (n=317) 27 REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES v

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9 Acknowledgements The development of the perception surveys and preparation of this report were led by Ms Kaia Engesveen with technical inputs and support from Dr Hana Bekele, Dr Férima Coulibaly-Zerbo and Dr Elisa Dominguez. Appreciation is extended to the larger WHO team, including Ms Monika Bloessner, Dr Francesco Branca, Dr Mercy Chikoko, Dr Chizuru Nishida, Dr Mercedes de Onis, Dr Adelheid Onyango and Ms Krista Zillmer, as well as to the WHO interns who supported the development of the survey tools and preparation of the report including Ms Ana Elisa Pineda, Ms Einat Schmutz, Ms Paula Veliz and Ms Line Vogt. WHO gratefully recognizes the work of Dr Jessica Fanzo (Johns Hopkins Bloomberg School of Public Health) who developed guidance for using the Performance Monitoring Framework of the project. Special thanks are also due to the WHO country office colleagues and their national counterparts who led the surveys: Burkina Faso: Dr Fousséni Dao (WHO), Ms Bertine Ouaro Dabiré and Mr Saidou Kabore (Ministère de la Santé) Ethiopia: Ms Etsegenet Assefa, Dr Kemeria Barsenga and Mr Getahun Teka Beyene (WHO), Ms Mulu Gebremedhin (John Snow, Inc.), Ms Yordanos Giday Hagos and Mr Birara Melese Yalew (Federal Ministry of Health) Mali: Dr Seybou Guindo (Ministère de la Santé), Dr Mohamed Ibrahim (Ministère de la Santé) and Dr Attaher Houzeye Toure (WHO) Mozambique: Dr Marla Amaro (Ministry of Health) and Dr Daisy Trovodada (WHO) Senegal: Dr Maty Diagne Camara (Ministère de la Santé et de l Action Sociale), Mr Ndiaye Djibril (consultant) and Dr Fatim Tall (WHO) Sierra Leone: Dr Aminata Shamit Koroma and Dr Solade Pyne-Bailey (Ministry of Health and Sanitation) and Ms Hannah Yankson (WHO) Uganda: Dr Baku Agnes Chandia and Dr Mwebembezi Edmond (Ministry of Health), Dr Priscilla Ravonimanantsoa (WHO), Mr Ssesanga Steven (MOH), Dr Bakunzi Maureen Tumusiime (Office of the Prime Minister) and Dr Florence Turyashemererwa-Biko (WHO) United Republic of Tanzania: Dr Isiaka Stevens Alo (WHO), Ms Mwashiga Augustino (Save the Children Fund Tanzania), Mr Gilagister Gwarassa (Tanzania Food and Nutrition Center), Mr Juma Peter Kaswahili (Ministry of Health and Social Welfare), Ms Rachel Alice Makunde (Save the Children Fund Tanzania), Mr Samson Ndimaga (TFNC) Zambia: Ms Agnes Aongola (Ministry of Health), Ms Chipo Misodzi Mwela (WHO) and Ms Dorothy Sikazwe (Ministry of Health) Zimbabwe: Mr Admire Chinjekure and Dr Trevor Kanyowa (WHO), Mr Joshua Katiyo (Ministry of Health) and Mr Nyadzayo Tasiana (Ministry of Health) REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES vii

10 Abbreviations ANI CSO DHS/EDS IYCF MAM MICS NGO PMF SAM SMART UN WHO Accelerating Nutrition Improvements in sub-saharan Africa Civil society organization Demographic and Health Survey/Enquête Démographique et de Santé Infant and young child feeding Moderate acute malnutrition Multiple Indicator Cluster Survey Nongovernmental organization Performance Monitoring Framework Severe acute malnutrition Standardized Monitoring and Assessment of Relief and Transitions United Nations World Health Organization ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) viii

11 Executive Summary The Accelerating Nutrition Improvements in sub-saharan Africa (ANI) project, implemented during the period , focused on strengthening nutrition surveillance in 11 countries (Burkina Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe). The project was supported by Global Affairs Canada and was implemented in close collaboration between the ministry of health, the World Health Organization (WHO) and local partners in respective countries. The progress of the ANI project was assessed using a Performance Monitoring Framework (PMF), which was developed in the beginning of the project. The PMF consisted of a set of quantitative and qualitative indicators with specific project performance targets to be reached during the implementation period. Four of the qualitative indicators were related to the perceptions and capacities of stakeholders: 1. Stakeholders awareness of the country s nutrition situation (target: 5) 2. Government capacity to collect and analyse nutrition data (target: 7) 3. Health workers capacity to deliver nutrition interventions (target: 75%) 4. Health workers capacity and confidence to carry out nutrition surveillance (target: 5). Information on these four indicators was gathered through perception surveys at the beginning and end of the project by each of the country teams. Five questionnaires were used to assess the perceptions of national and district level government representatives, development practitioners, health workers and media. Algorithms were created for aggregating the perception survey results into one indicator value per country. This report presents the results of 767 baseline and 498 end-line interviews in ten countries, and the level of achievement of the project performance targets on the four perception and capacity indicators. Rwanda was not included in the analysis, due to the timing of their interventions. The results of the perception surveys show that important perception and capacity changes can be achieved among government officials, health workers and other stakeholders in a relatively short but intense period. For instance, seven out of ten countries attained the project performance target related to awareness of the country s nutrition situation. While stakeholders were most familiar with the problems of stunting and wasting, the awareness of problems related to anaemia, low birth weight, overweight and low rates of exclusive breastfeeding increased over the project period. Health workers perceptions of their capacity for delivering nutrition services and performing nutrition surveillance also increased over the project period. In all three countries supported to implement scaling-up of nutrition actions (Ethiopia, Uganda and the United Republic of Tanzania), health workers capacity to deliver nutrition interventions, such as infant and young child feeding counselling and the management of severe acute malnutrition, was strengthened. Furthermore, in seven out of ten countries, health workers capacity and confidence to perform nutrition surveillance increased. On the other hand, no country reached the project performance target concerning government capacity for nutrition surveillance. This may be attributable to the fact that the survey assessed REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES ix

12 stakeholders perceptions of government capacity rather than the government s actual capacity to conduct nutrition surveillance. Overall, government capacity for undertaking surveys was perceived higher than the capacity for conducting routine data collection. The perception surveys can serve as important tools for assessing stakeholders understanding and views on nutrition problems being faced in their communities, districts or countries as well as their capacity to address those problems. This, in turn, will help to identify required actions to guide the delivery of nutrition interventions. ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) x

13 I. Introduction The Accelerating Nutrition Improvements in sub-saharan Africa (ANI) project, implemented during the period , had three components: strengthening of nutrition surveillance in 11 countries (Burkina Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe); carrying out nutrition surveys in four countries (Rwanda, Sierra Leone, Zambia and Zimbabwe); and scaling up nutrition interventions in three countries (Ethiopia, Uganda and the United Republic of Tanzania). The ANI project was supported by Global Affairs Canada and was implemented in close collaboration between the ministry of health, the World Health Organization (WHO) and local partners in respective countries. The progress of the ANI project was assessed using a Performance Monitoring Framework (PMF), developed in the beginning of the project implementation period. The framework consists of a set of quantitative and qualitative indicators, of which four concern the perceptions and capacities of different stakeholders: 1. Policy-makers, development practitioners, and media with awareness of the country s nutrition situation, and an understanding/conviction that nutrition is a national priority for investment. 2. Government capacity to collect and analyse nutrition data collected from the surveys (those who perceive they have the knowledge and skills to collect and analyse the data). 3. Health workers capacity to deliver nutrition interventions to women and children in ANI districts (who perceive that their knowledge and skills have improved). 4. Health workers perception of their capacity (and confidence) to carry out nutrition surveillance. Information on these indicators was collected through surveys at baseline and end-line of the project. Ten of the eleven ANI countries performed the full survey at baseline and an abbreviated version at end-line. One country, Rwanda, carried out the baseline survey in October 2015 after having implemented various capacity building activities and thus did not conduct an end-line survey. This report presents the results of the surveys, hereafter referred to as perception surveys, in ten countries. REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 1

14 II. Methods The perception surveys were developed based on the WHO Landscape Analysis country assessment tools and methodology, 1 which have been applied in 19 countries 2 to date. A detailed description of the methodology, including sampling and interview techniques, can be found in the ANI PMF Guide (WHO, 2014). Survey tools The survey tools consisted of five questionnaires (Table 1), with corresponding data entry sheets. All five questionnaires were used to collect data at baseline, while shorter versions of four of the questionnaires 3 were used at end-line. Recommended sample sizes remained the same at baseline and end-line. Table 1. Questionnaire tools, target groups and recommended sample sizes per country ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) QUESTIONNAIRE TOOL EXAMPLE OF TARGET GROUP RESPONDENTS RECOMMENDED SAMPLE SIZE 1. National level government Director of Nutrition Programme, Director of Health Promotion Department, Director of Food Security and Nutrition, School Health Manager 2. Development practitioners UN, NGOs, CSOs and donors Media Journalists, writers, television and radio producers/creators, press 5 4. District level government District Health Manager, District Chief Health Officer, District Agriculture Extension Supervisor, local authorities involved in decisions on nutrition 10 issues 5. Health workers Community health worker, midwife, child health nurse 20 Timing of surveys The baseline perception surveys were conducted between April 2014 and February 2015, and the end-line surveys between May and October As far as possible, the baseline perception surveys were carried out through integration into other planned surveys or activities to avoid creating an additional burden for the countries. For example, in Uganda and the United Republic of Tanzania, they were conducted in conjunction with district assessments, and in Ethiopia. they were carried out along with a pilot coverage survey and a surveillance gap assessment Questionnaires 1,2,4 and 5. Questionnaire 3, directed towards media, was not repeated as none of the countries implemented specific activities addressing media in the context of the ANI project. 2

15 Implementation of surveys in countries In all countries, the assessment team was led by national government staff and supported by WHO and partners. Country teams adapted the tools to suit the local health services and infrastructure as well as the public administrative realities, selected target respondents and sites, trained data collection teams, collected the data and performed country analyses and reporting. Many countries also presented the results at national stakeholder meetings. Global level analyses Data from all countries were cleaned, harmonized and merged at the global level by WHO headquarters. Analyses included descriptive statistics and assessment of the four ANI PMF indicators, which were subsequently included in the ANI PMF baseline and end-line reports. Assessment of the ANI PMF indicators Assessing the four perception indicators required creating algorithms for aggregating the rich perception survey datasets into one indicator value per country. PMF Intermediate outcome 1300: Awareness of the country s nutrition situation Awareness of the country s nutrition situation was assessed through open-ended questions to national and district level stakeholders. Responses were coded straightaway into previously defined categories related to nutrition problems and their immediate, underlying and basic causes. Perceptions related to the priority given to nutrition by the government were also assessed. This indicator was defined as the proportion of stakeholders surveyed who are aware of the nutrition situation, and had a target of 5 (WHO, 2014). The algorithm to estimate the indicator was defined as the proportion of stakeholders who mentioned more than half of the existing Global Nutrition Target-related nutrition problems in their country. In other words, awareness around any one Global Nutrition Target was only considered if this constituted a problem in the country. To determine whether a country had a Global Nutrition Target-related problem or not, data from the most recent national surveys available in countries were assessed against established cut-off values (for stunting, wasting and anaemia), cut-off values derived from the global target (overweight and exclusive breastfeeding), or those used in previous similar analyses (low birth weight) (Table 2 and Table 3). Individual responses were analysed to count the number of existing Global Nutrition Target-related problems mentioned in their countries, and the ANI PMF indicator was calculated as the proportion of stakeholders who mentioned more than half of these problems. PMF Immediate outcome 1120: Government capacity for nutrition surveillance The survey questionnaires explored various aspects of capacity for conducting nutrition surveillance at national, district and health facility levels. Information was gathered on data collection, flow between different levels, reporting and use in routine surveillance and in surveys. Respondents were also asked how they perceived and would rate government capacity to collect, analyse and report nutrition survey and routine data. This indicator was defined as the proportion of government respondents who have the capacity to do surveillance, and had a target of 7 (WHO, 2014). However, clearly not all individual government respondents at national and district levels need to have skills to collect and analyse nutrition data. Therefore, rather than focusing on individual capacity, the algorithm was defined as the proportion of high or very high ratings of government capacity to perform any of the aspects of nutrition surveillance. REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 3

16 ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Table 2. Country data related to the 2025 Global Nutrition Targets: prevalence and year Red colour indicates that the value is within the cut-off level used for indicating a nutrition problem. Burkina Faso Ethiopia Mali Mozambique Senegal Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe End-line End-line End-line End-line End-line End-line End-line End-line End-line End-line Stunting Anaemia Low birth weight Overweight Exclusive breastfeeding Wasting 31.5% 49.5% (2010) 10.3% 2% (2014) 47.2% 8.2% 30.2% (2015) 61.9% (2014) 9.8% (2014) 1% (2015) 46.7% 2015) 10.4% (2015) 44% 17% 11% 1.7% 52% % (2016) 23% (2016) 11% 2.8% (2016) 58% (2016) 9.9% (2016) 27.5% 51.4% (2012) 18% (2010) 4.7% (2010) (2012) 8.6% 23.1% (2016) 51.4% (2012) 16% (2012) 4.7% (2010) (2012) 11.5% (2016) 43% 52.4% 14% 7.1% 6.7% 43% 52.4% 14% 7.1% 6.7% 18.7% 54% 1.3% (2014) 1.4% 38% 8.7% 19.4% (2014) 54% 1.3% (2014) 0.3% (2016) (2015) 5.8% (2014) 34.1% (2010) 45% (2008) 11% (2008) 8.4% (2008) 32% (2010) 6.9% (2010) 28.8% (2014) 45% 7% 7.5% 58% (2014) 4.7% (2014) 33.4% 23% 10.2% 3.4% 63% 4.7% % 10.2 % 3.4% 63% 4.7% 42% (2010) 40 % (2010) 7% (2010) 5% (2010) 5 (2010) 4.8% (2010) 34. (2015) 45 % (2015) 7% (2015) 4% (2015) 59% (2015) 4.5% (2015) % 9% 1% 73% 6% 40. ZAM 29.2% 9% 1% 73% 6% 32% ( ) 28% ( ) 1 ( ) 6% ( ) 31% ( ) 3% ( ) 27% (2015) 27% (2015) 1 (2015) 6% (2015) 48% (2015) 3% (2015) Data sources: Burkina Faso: Stunting, overweight, wasting, exclusive breastfeeding from Standardized Monitoring and Assessment of Relief and Transitions (SMART) surveys 2013, 2104 and 2015; anaemia among women of reproductive age from Demographic and Health Survey (DHS Enquête démographique et de santé (EDS)) 2010 and from Iodine and anaemia nutrition survey (Enquête nutritionnelle iode et anémie Burkina Faso (ENIAB)) 2014; low birth weight from annual statistic bulletin (annuaire statistique) 2013 and Ethiopia: DHS 2011, DHS Mali: Stunting, wasting from SMART surveys 2013 and 2016; anaemia among women of reproductive age and exclusive breastfeeding from DHS 2012; low birth weight from Multiple Indicator Cluster Survey (MICS) 2010 and DHS 2012; overweight from DHS Mozambique: DHS Senegal: Stunting, low birth weight, overweight, wasting from continuous DHS (EDS continue) 2013 and 2014 and ANI sentinel surveillance 2016; anaemia among women of reproductive age from National survey on food security and nutrition (Enquête nationale sur la sécurité alimentaire et la nutrition (ENSAN)) 2013; exclusive breastfeeding from continuous DHS (EDS continue) 2013 and Sierra Leone: Stunting, exclusive breastfeeding and wasting from Sierra Leone Nutrition Survey (SLNS) 2010 and 2014; anaemia among women of reproductive age, low birth weight and overweight from DHS 2008 and Uganda: DHS 2011 except for anaemia which is prevalence estimate for 2011 published by WHO (2015): The global prevalence of anaemia in United Republic of Tanzania: DHS 2010, DHS Zambia: DHS Zimbabwe: DHS , DHS

17 Table 3. Cut-off values used to determine country-relevant nutrition problems GLOBAL NUTRITION TARGET CUT-OFF VALUE USED SIGNIFICANCE/REASON REFERENCE Stunting 2 Level of public health significance (WHO, 1995) Anaemia 2 Moderate or severe problem (WHO, 2008) Low birth weight 1 Used in previous similar analyses (WHO, 2013) Child overweight 7% Represents a higher rate than the global level baseline (WHO, 2014) Exclusive breastfeeding < 5 Represents a non-attainment of global target (WHO, 2014) Wasting 5% Unacceptable level (WHO, 1995) PMF Immediate outcome 1220: Health workers capacity to deliver nutrition interventions To assess health workers capacity to deliver nutrition interventions in the three countries that were supported to scale up nutrition actions, the survey explored health workers knowledge of and confidence to deliver essential nutrition actions, their training and their perceived adequacy of time to provide nutrition services. This indicator was defined as the proportion of health workers surveyed who perceive that they have the knowledge to deliver nutrition services, and had a target of 75% (WHO, 2014). The algorithm for this indicator was set as the proportion of health workers who answered correctly a minimum of six out of eight knowledge questions, concerning the delivery of micronutrient supplementation to pregnant women, early initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding, HIV and breastfeeding, timely introduction of complementary feeding, hospital-based management of severe acute malnutrition (SAM), and promotion of healthy diets and lifestyles. PMF Intermediate outcome 1100: Health workers capacity and confidence to do nutrition surveillance Health workers capacity and confidence to do nutrition surveillance was assessed by their knowledge of and confidence around growth monitoring and anthropometry, their training and their perceived adequacy of time to conduct nutrition surveillance. This indicator was defined as the proportion of health workers who feel confident to do nutrition surveillance, and had a target of 5 (WHO, 2014). The algorithm for this indicator was set as the proportion of health workers who feel confident about most or every aspect of carrying out conventional nutrition surveillance activities, for example taking anthropometric measurements, plotting and interpreting growth charts, completing child health cards and analysing nutrition data. REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 5

18 III. Results Responses A total of 767 baseline and 498 end-line interviews were conducted with stakeholders at national, district and facility levels (Table 4). Nine countries reached most of the recommended sample sizes described at baseline (three countries met all), whereas six countries met most of the recommended sample sizes at end-line (five countries met all). The higher number of interviews at baseline was mainly due to very large sample sizes among district officials and health workers in two countries (Uganda and Zambia); these were more than four times the recommended sample sizes. ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Perception of the nutrition situation and priorities in countries Awareness of Global Nutrition Target-related problems in countries At baseline, four countries (Ethiopia, Mali, Mozambique and the United Republic of Tanzania) had already reached the target of 5 or more of respondents being aware of more than half of the relevant Global Nutrition Target-related problems in their countries, while at end-line this had increased to seven countries (Burkina Faso, Ethiopia, Mali, Senegal, Sierra Leone, the United Republic of Tanzania and Zambia) (Figure 1). Awareness more than doubled in three countries (Burkina Faso, Sierra Leone and Zambia), whereas in four countries (Mali, Mozambique, Uganda and Zimbabwe) there was a decrease in awareness of country-relevant problems. Stunting was perceived as a problem by a majority of respondents in all countries at both baseline and end-line (Figure 2), including in Senegal where national stunting rates were just below the 2 cut-off value for public health significance. Wasting was mentioned as a problem by a majority of respondents in most countries at both baseline and end-line. Exceptions were Uganda, the United Republic of Tanzania and Zimbabwe where the wasting rates were below the 5% cut-off value for acceptable prevalence. At end-line, a majority of respondents in four countries (Ethiopia, Sierra Leone, the United Republic of Tanzania and Zambia) reported anaemia as a key problem in their countries. Low birth weight and overweight were perceived as nutrition problems by fewer than 25% of respondents in most countries at baseline and in many countries at end-line. Anaemia, low birth weight, overweight and exclusive breastfeeding were perceived as problems more than twice as often at end-line compared to baseline in four countries (Burkina Faso, Ethiopia, Sierra Leone and Zambia). All respondent groups interviewed at both baseline and end-line (government, development practitioners and district level stakeholders) mentioned more problems related to the Global Nutrition Targets at end-line than baseline (Figure 3). Low birth weight, overweight and exclusive breastfeeding were mentioned more than twice as often by government and district officials at end-line than at baseline; mention of wasting remained stable. Media respondents, who were only interviewed at baseline, generally mentioned problems related to the Global Nutrition Targets less frequently than other respondents. 6

19 Table 4. Number of respondents by respondent group Green colour indicates that the recommended sample size was reached. 1. GOVERNMENT 2. DEVELOPMENT PRACTITIONER 3. MEDIA 4. DISTRICT 5. HEALTH WORKER TOTAL BASELINE Burkina Faso Ethiopia Mali Mozambique Senegal Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe subtotal END-LINE Burkina Faso Ethiopia Mali Mozambique Senegal Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe End-line subtotal Grand Total REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 7

20 Figure 1. Indicator 1300: Awareness of a majority of country-relevant problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) % Burkina Faso (n=43; 47) 54% 97% Ethiopia (n=41; 30) 54% 5 Mali (n=41; 30) 66% 46% Mozambique (n=29; 13) 42% 62% Senegal (n=43; 29) 97% Sierra Leone (n=44; 39) 29% Uganda (n=58; 28) 69% 97% United Republic of Tanzania (n=26; 33) 47% Zambia (n=73; 22) End- line 29% 26% Zimbabwe (n=52; 27) ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Awareness of nutrition problems and causes beyond the Global Nutrition Targets Among all respondents in all the countries, problems related to child undernutrition were most commonly mentioned, followed by vitamin and mineral deficiencies and by undernutrition among women (Figure 4). Whereas 96% of respondents mentioned child undernutrition as a problem in their countries, they generally referred to stunting and wasting. Only 19% specified low birth weight at baseline; this increased to 43% at end-line. Similarly, whereas more than 5 of respondents mentioned undernutrition among women as a problem in their countries, they generally referred to anaemia or underweight. Short stature in women was only mentioned by 6% of respondents at baseline, which increased to 18% at end-line. Reference to low birth weight, short stature among women, overweight in children and adults, iodine deficiency and vitamin A deficiency more than doubled between baseline and end-line. Perception of all main problem groups (child undernutrition, undernutrition among women, overweight and obesity, and vitamin and mineral deficiencies) increased in five countries (Burkina Faso, Ethiopia, Sierra Leone, the United Republic of Tanzania and Zambia) from baseline to endline (Figure 5). The proportions more than doubled for overweight and obesity in four countries (Burkina Faso, Ethiopia, Sierra Leone and Zambia), for undernutrition in women in three countries (Ethiopia, the United Republic of Tanzania and Zambia) and for vitamin and mineral deficiencies in two countries (Burkina Faso and Zambia). The most commonly mentioned causes of nutrition problems were food insecurity, lack of knowledge, inadequate infant and young child feeding (IYCF) and caring practices, disease burden, poverty and insufficient health services or unhealthy environments (Figure 6 and Figure 7). Perception of a causal relationship between nutrition problems and the lack of recommended breastfeeding practices, inadequate sanitation, inadequate hygiene, unclean water, increasing food prices, malaria and disasters increased by more than two-fold between baseline and end-line. 8

21 Figure 2. Problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) StunJng Anaemia Low birth weight Overweight Exclusive breasreeding WasJng 21% 19% 12% 28% 12% 1 5% 32% 22% 15% 24% 17% 2 14% 27% 27% 15% 23% 21% 16% 28% 37% 37% 45% 43% 4 42% 31% 31% 38% 47% 46% 48% 62% 57% 58% 69% 77% 76% 76% 73% 84% 79% 76% 98% 94% 93% 9 97% 95% 93% 88% 97% End- line End- line End- line End- line End- line Burkina Faso (n=43; 47) Ethiopia (n=41; 30) Mali (n=41; 30) Mozambique (n=29; 13) Senegal (n=43; 29) 64% 9% 9% 27% 84% 72% 69% 21% 17% 11% 14% 18% 12% 15% 18% 1 3% 29% 36% 32% 38% 27% 42% 39% 39% 42% 27% 17% 19% 15% 13% 15% 15% 7% 19% 77% 81% 57% 68% 65% 73% 55% 58% 64% 68% 67% 54% 67% 95% 97% 92% 91% 95% End- line End- line End- line End- line End- line Sierra Leone (n=44; 39) Uganda (n=58; 28) United Republic of Tanzania (n=26; 33) Zambia (n=73; 22) Zimbabwe (n=52; 27) 14 REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 9

22 ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Figure 3. Problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by type of respondent (n= 450 at baseline, 298 at end-line) Stun^ng Anaemia Low birth weight Overweight Exclusive breasaeeding Was^ng 85% 37% 14% 14% 19% 8 45% 42% 36% 29% 21% 48% 36% 49% 9% 11% 11% 16% 44% 92% 59% 54% 83% 91% 76% 97% 62% 63% 74% % 12% 17% 73% 81% 38% 36% 3 44% 75% (n=97) End- line (n=92) (n=97) End- line (n=95) (n=55) (n=201) End- line (n=111) 1. Government 2. Development prac^onner 3. Media 4. District 10

23 Figure 4. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development practitioners and media (n= 450 at baseline, 298 at end-line) 96% 96% 71% 9 72% 78% 19% 43% 56% 68% 3 52% 6% 18% 24% 47% 29% 51% 14% 39% 21% 44% 5 77% 42% 72% 19% 43% 24% 59% End- line REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 16 11

24 ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Figure 5. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) Child undernutrijon UndernutriJon in women Overweight and obesity Vitamin and mineral deficiencies 1 15% 26% 2 37% 37% 47% 44% 49% 47% 59% 54% 49% 48% 48% 61% 68% 66% 62% 7 67% 79% 8 74% 72% 85% 91% 98% 98% 97% 98% (n=63) End- line (n=69) (n=53) End- line (n=50) (n=61) End- line (n=50) (n=44) End- line (n=20) (n=61) End- line (n=48) Burkina Faso Ethiopia Mali Mozambique Senegal 2 21% 15% 22% 29% 29% 25% 35% 3 46% 42% 55% 53% 5 49% 61% 58% 73% 69% 79% 81% 88% 85% 79% 82% 95% 9 95% 98% 97% 94% (n=66) End- line (n=61) (n=129) End- line (n=62) (n=58) End- line (n=58) (n=155) End- line (n=33) (n=77) End- line (n=47) Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe 17 12

25 Figure 6. Causes of nutrition problems as perceived by respondents representing government at national and district level, development practitioners and media (n= 450 at baseline, 298 at end-line) 69% 76% 52% 72% 12% 29% 46% 7 16% 26% 18% 42% 63% 24% 53% 17% 39% 16% 46% 2 36% 61% 73% 21% 5 7% 31% 1 19% 32% 3 53% 5 68% 76% 56% 65% 38% 86% 85% End- line 18 REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 13

26 ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Figure 7. Causes of nutrition problems as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) Food insecurity Disease burden Insufficient health services or unhealthy environment Inadequate caring and IYCF pracqces Lack of knowledge Poverty (lack of money) 15% 23% 22% 19% 17% 39% 37% 28% 38% 51% 49% 56% 49% 66% 62% 68% 55% 49% 51% 51% 61% 49% 51% 48% 46% 63% 53% 49% 53% 69% 81% 94% 85% 98% 93% 83% 8 93% 83% 67% 57% % 59% 54% 46% 46% 55% 62% 71% 73% 69% 79% 72% 79% 77% 77% 7 67% 83% 76% 93% 88% 97% (n=63) End- line (n=69) (n=53) End- line (n=50) (n=61) End- line (n=50) (n=44) End- line (n=20) (n=61) End- line (n=48) Burkina Faso Ethiopia Mali Mozambique Senegal 7% 3% 11% 19% 18% 13% 27% 27% 21% 31% 3 36% 43% 26% 37% 35% 44% 42% 3 22% 26% 37% 44% 3 61% 66% 59% 66% 57% 71% 81% 82% 79% 91% 86% 69% 64% 78% 84% 71% 61% 62% 71% 69% 67% 58% 67% 61% 68% 65% 62% 72% 85% 88% 88% 97% 95% 97% 95% (n=66) End- line (n=61) (n=129) End- line (n=62) (n=58) End- line (n=58) (n=155) End- line (n=33) (n=77) End- line (n=47) Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe 19 14

27 Government priority for nutrition Commitment to nutrition requires both awareness and priority-setting. A higher proportion of respondents perceived that the government gave a high or very high priority to nutrition at end-line in three countries as compared to baseline in ten countries (Figure 8). More than half of the respondents in four countries (Burkina Faso, Mali, Senegal and Sierra Leone) indicated that government made nutrition a high or very high priority (Figure 9). At baseline in ten countries, the perceptions about government giving high or very high priority to nutrition were most common among government employees, whereas at end-line in three countries similarly high ratings were also seen among health workers and district officials (Figure 10). At baseline, health workers in ten countries assessed their own commitment to nutrition higher than that of the decision-makers, whereas at end-line in three countries their assessment was more comparable (Figure 11). Figure 8. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line (n=767 at baseline, 167 at end-line) % 4% 18% 24% 53% 14% 25% 1. Very low 2. Low 3. Medium 4. High 5. Very high End- line REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 15

28 ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Figure 9. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line, by country (n=767 at baseline, 167 at end-line) 1% 1% 2% 6% 13% 3% 8% 7% 5% 5% 2% 4% 2% 5% 11% 8% 9% 19% 18% 21% 3 25% 15% 9% 12% 22% 16% 22% 14% 26% 35% 35% 32% 25% 38% 28% 35% 47% 4 39% 3 21% 14% 23% 36% 26% 16% 9% 16% 11% 25% 18% 26% 23% 22% 21% 36% 38% 51% 71% (n=63) End- line (n=69) 1. Very low 2. Low 3. Medium 4. High 5. Very high (n=53) (n=61) End- line (n=50) (n=44) (n=61) End- line (n=48) (n=66) (n=129) (n=58) (n=155) (n=77) Burkina Faso Ethiopia Mali Mozambique Senegal Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe Figure Government priority priority for nutrition for nutrition as perceived as perceived by all respondents by all respondents in ten countries in ten at countries baseline and at baseline three countries and in three at end- line, countries by type at of end-line, respondent by (n=76 at baseline, 167 type at end- line) of respondent (n=767 at baseline, 167 at end-line) 5% 1 25% 36% 24% 2% 2 64% 14% 3% 23% 44% 28% 2% 3% 1 43% 3 13% 14% 26% 4 14% 6% 14% 18% 21% 14% 6% 9% 1 17% 22% 17% 56% 28% 8% 56% 36% Very low 2. Low 3. Medium 4. High 5. Very high (n=97) End- line (n=44) (n=97) End- line (n=30) (n=55) (n=201) End- line (n=32) (n=317) End- line (n=61) 1. Government 2. Development pracxonner 3. Media 4. District 5. Health worker 21 16

29 Figure 11. Health workers perception of priority given to nutrition by decision-makers and by themselves in their daily work in ten countries at baseline and in three countries at end-line (n=317 at baseline, 61 at end-line) Very low 2. Low 3. Medium 4. High 5. Very high 1 17% 22% 17% 8% 56% 36% 5% 8% 22% 29% 36% 1 39% 51% (n=317) End- line (n=61) (n=317) End- line (n=61) Decision makers make nutri^on a priority Health workers make nutri^on a priority Perception of nutrition surveillance Government capacity for nutrition surveillance No country achieved the ANI PMF target of 7 for this indicator (Figure 12). Small increases in rating were observed in six countries (Burkina Faso, Mali, Senegal, Uganda, the United Republic of Tanzania and Zambia); the full distribution within each country is shown in Figure 13. Government staff most often rated themselves as having high or very high capacity for nutrition surveillance (Figure 14). Overall, the capacity for undertaking surveys was perceived higher than for performing routine data collection (Figure 15). Figure 12. Indicator 1120: Perceived high or very high government capacity for nutrition surveillance as reported by respondents representing government at national and district level and development practitioners, by country (n=395 at baseline, 298 at end-line) % 51% Burkina Faso (n=37; 47) 24% Ethiopia (n=36; 30) 44% Mali (n=35; 30) 3 27% Mozambique (n=25; 13) 43% 48% Senegal (n=38; 29) 22 43% Sierra Leone (n=39; 39) 13% 19% Uganda (n=53; 28) 31% 36% United Republic of Tanzania (n=21; 33) 44% Zambia (n=65; 22) 55% End- line 43% Zimbabwe (n=46; 27) REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 17

30 ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Figure 13. Government capacity for nutrition surveillance as perceived by respondents representing government at national and district level and development practitioners, by country (n=395 at baseline, 298 at end-line) 1% 13% 7% 8% 11% 8% 21% 29% 37% 42% 44% 25% 29% 26% 14% 23% 38% 2 4% 7% 23% 36% 23% 1 1% 18% 38% 1 13% 26% 31% 27% 3% 39% 26% 1% 4% 21% 32% 37% 6% 7% 45% 39% 9% Very low 2. Low 3. Medium 4. High 5. Very high (n=37) End- line (n=47) (n=36) End- line (n=30) (n=35) End- line (n=30) (n=25) End- line (n=13) (n=38) End- line (n=29) Burkina Faso Ethiopia Mali Mozambique Senegal 1% 23% 9% 13% 45% 37% 5% 13% 4 13% 1% 11% 22% 37% 27% 4% 2 27% 15% 4% 6% 23% 7% 8% 19% 11% 3% 8% 6% 3% 9% 2 3% 13% 25% 18% 35% 29% 32% 3 45% 37% 35% 42% (n=39) End- line (n=39) (n=53) End- line (n=28) (n=21) End- line (n=33) (n=65) End- line (n=22) (n=46) End- line (n=27) Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe 23 18