LANDSCAPE ANALYSIS TO ACCELERATE ACTIONS TO REDUCE MATERNAL AND CHILD UNDERNUTRITION SRI LANKA

Transcription

1 LANDSCAPE ANALYSIS TO ACCELERATE ACTIONS TO REDUCE MATERNAL AND CHILD UNDERNUTRITION SRI LANKA Dr. Renuka Jayatissa Dr. Dulitha Fernando Medical Research Institute In collaboration with World Health Organization MINISTRY OF HEALTH, SRI LANKA September 2

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3 LIST OF ABBREVIATIONS BFHI BMI CHDR CMC CMOH CWC DDGPHS DGHS ECCD FHB HDC HEB IDD IEC IMCI INGO IYCF MAM M & E MCH MCN MDG MOH MoH MOMCH MRI NCD Baby Friendly Hospital Initiative Body Mass Index Child Health Development Record Colombo Municipal Council Chief Medical Officer of Health Child Welfare Clinic Deputy Director General, Public Health Services Director General of Health Services Early Childhood Development Family Health Bureau Health Development Committee Health Education Bureau Iodine Deficiency Disorders Information, Education, Communication Integrated Management of Childhood Ilnness International n Governmental Organizations Infant and Young child feeding Moderate Acute Malnutrition Monitoring and Evaluation Maternal and Child Health Maternal and Child Nutrition Millennium Development Goals Medical Officer of Health Ministry of Health Medical Officer Maternal and Child Health Medical Research Institute n Communicable Diseases Page iii

4 NFSS NGO NNC NSCN NRP NSACP ORS PCs PDHS PH PHI PHM PHNS RE RHIS RSPHNS SMI SPHI SPHM SPHID TAC ToT UNICEF WFP WHO Nutrition and Food Security Survey n Governmental Organisation National Nutrition Council National Steering Committee on Nutrition Nutrition Rehabilitation Programme National STD/AODS Control programme Oral Rehydration Solution Provincial Councils Provincial Director of Health Services Public Health Public Health Inspector Public Health Midwife Public Health Nursing Sister Regional Epidemiologist Reproductive Health Information System Regional Supervising Public Health Nursing Sister School Medical Inspection Supervising Public Health Inspector Supervising Public Health Midwife Supervising Public Health Inspector Divisional Technical Advisory Committee Training of Trainers United Nations Childrens Fund World Food Programme World Health Organisation Page iv

5 PREFACE Page v

6 MESSAGE FROM WHO REPRESENTATIVE Page vi

7 ACKNOWLEDEMENTS We gratefully acknowledge the continued valuable and constructive advice provided by Dr. L. Siyambalagoda, Deputy Director General Public Health Services, Ministry of Health. We also deeply acknowledge the fruitful and motivating discussions and support from the members of the Coordinating Committee and tireless continous inputs from members of the working committee, especially during the stage of the data collection and analysis. Many thanks go to Director, MRI and staff. Deep gratitude goes to the WHO, particularly Dr. R. Mehtha, Country Representative, WHO, Dr. Anoma Jayatilaka (National Programme Officer), Dr. Nizhida Chizuru, Dr. Kunal Bachchi, Ms.Kaia Envergeseen, WHO Geneva for their continued support throughout the study, with special emphasis on data analysis. Special thanks go to all stakeholders at the national, provincial, district, divisional and feild levels, who contributed to this study by providing valuable information on which this report is based. We deeply acknowledge Secretary of Health, Additional Secretary of Health, DGHS, all the DDGHs for their willingness and for expressing their views which contributed to the quality of information included in this report. They, patiently, answered all the questions and provided valuable insights. Many thanks go to the staff at MRI, Nutrition department including team of investigators, doctors, data entry and analyse teams for making this study, a success. Page vii

8 RESEARCH TEAM Principal investigators Dr. Renuka Jayatissa Dr. Dulitha Fernando - Consultant Medical Nutritionist & Head, Department of Nutrition, MRI - Former Prof. of Community Medicine, Faculty of Medicine, Working Group Members Dr. S.M.A.S. Mahamithawa Dr. Anoma Jayathilaka Dr. Dula De Silva Dr. S.M. Moazzem Hossain Ms.Visaka Tilakaratna -Deputy Director, Nutrition - Programme officer, WHO - Programme officer, WFP -Chief,Health and Nutrition,UNICEF -Consultant, World Bank Coordinating Committee Members Dr. L. Siyabalagoda (Chairperson) Dr. Renuka Jayatissa (Convener) Dr. Sarath Amunugama Dr. M. Samaranayaka Dr. Shanthi Gunawardana Dr. Ayesha Lokubalasuriya Dr. Dula De Silva Dr. S.M. Moazzem Hossain Miss Vishaka Tilakaratne - DDG(PHS), Ministry of Health - Consultant Medical Nutritionist & Head, Department of Nutrition, MRI - Director, HEB -Director, Nutrition Division. -Actg. Director, Nutrition Coordination Division - Consultant Community Physician, FHB. - Programme officer, WFP -Chief,Health and Nutrition,UNICEF -Programme officer, World Bank International Advisors Dr. Nishida Chizuru Dr. Kunal Bachchi Ms. Kaia Engesveen - Global Advisor, Nutrition, WHO- HQ - Regional Advisor, Nutrition, WHO - SEARO - Technical Officer, WHO, HQ Page viii

9 Survey Team Dr. A.T.D. Dabare Dr. Sandya Gunawardana Mr. J.M. Ranbanda Dr.W.I Gankanda Dr.I.A.G.M.P Gunathilake Miss.C.G Uduwaka Mr. A.P. Senevirathne Mr. H.K.T. Wijayasiri Mr. P.V.N. Ravindra Mr. E.G.S. Kulasinghe Mr. W.A.P.I. Pieris Mr. E.C. Paranagama Mr. D.S. Dabare Mr. P.A.K.Y. Wijesundara Mrs. K.H.R. Shyamalee Mrs. W.R.T.S. Perera Miss H.I.K.N. Hevawitharana Miss.C.B. Wijemanna Miss. G.C. Priyadarshani - Medical Officer - Medical Officer - Nutrition Assistant - Pre-intern Research assistant - Pre-intern Research assistant - Research assistant - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Public Health Inspector - Development Assistant - Development Assistant - Development Assistant - Data Entry Operators - Data Entry Operators Page ix

10 TABLE OF CONTENTS LIST OF ABBREVIATIONS... iii PREFACE... v MESSAGE FROM WHO REPRESENTATIVE... vi ACKNOWLEDEMENTS... vii RESEARCH TEAM... viii TABLE OF CONTENTS... x LIST OF TABLES... xv LIST OF FIGURES... xviii EXECUTIVE SUMMARY... xix PART I... Background..... Sri Lanka Country profile....2.health status indicators Public Health Services in Sri Lanka... 4 Financing of health care services... 7 Role of n Governmental Organizations (NGOs) An overview of the nutrition situation in Sri Lanka... 8 Nutritional status and determinants... 8 Low birth weight (LBW):... 9 Nutritional status of infants and children under five years of age... 9 School children.... Nutritional status of non pregnant women... 2 Page x

11 Nutritional status among pregnant women... 2 Adults... 3 Micronutrient Deficiencies... 3 Anaemia... 3 Iodine deficiency... 4 Vitamin A deficiency Determinants of Malnutrition... 6 Determinants of low birth weight... 6 Child under nutrition... 8 Determinants of under nutrition among women... 9 PART I I In depth country assessment - Sri Lanka Purposes of the Landscape Analysis assessment Study instruments Methodology Results Commitment to act Political commitment Awareness of nutrition problems and underlying causes among stakeholders Willingness of partners to contribute to scaling-up of nutrition actions Perceived barriers for scaling up of nutrition actions Commitments of stakeholders to scale up nutrition action Focused policies and regulations at central level with supporting plans and protocols at the sub national levels Specific and appropriate nutrition policies, strategies and actions plans at the central level Page xi

12 Views of stakeholders on nutrition policies Integration of nutrition into provincial and district level plans Incorporating nutrition into plans and programmes in the health sector Integration into other sectoral programmes Legislation enacted to support nutrition activities Prioritized and evidence informed nutrition interventions Updated protocols for key nutrition programmes and interventions Resource mobilization at central level and budget provision at sub national level Perception of stakeholders regarding resource availability Coordination, involvement of partners and support for sub national levels Coordination of nutrition activities Involvement of government sectors and partners in nutrition coordination Involvement of partners... 5 Scope of nutrition interventions by n Governmental Organizations (NGOs)... 5 Use of Millennium Development Goals (MDGs) Support to districts and facilities Availability of nutrition data Support received by district managers Orientation and training at launch of programmes Capacity to act Human resources and quality of services Distribution of staff with appropriate skills at all levels Availability of nutrition mangers at central level with degrees in nutrition Distribution of skilled staff at different levels of administration and service delivery In service training Page xii

13 Capacity of staff at all levels... 6 Availability of training opportunities... 6 Availability of relevant and updated training materials in local languages Availability of follow up training or post training supervision Health worker s knowledge Confidence of staff to address nutrition problems Health worker capacity, motivation and time/place for counselling... 7 Nutrition education and counselling Staff motivation at all levels Support received from higher levels Training and support needs of facility staff Satisfaction with nutrition programmes Quality of services in facilities and follow up Management systems and supplies Management systems Appropriately trained nutrition co-ordinators in each district Information systems Supplies Demand side factors Client knowledge and satisfaction Information on the utilization of nutrition services IEC materials Community engagement strategies Mothers' support group availability and frequency of meetings Page xiii

14 PART III Provincial Information Provincial profile- Central Province Provincial profile- Eastern Province Provincial profile- rthern Province Provincial profile- rthcentral Province Provincial profile- rthwestern Province Provincial profile - Sabaragamuva Province Provincial profile - Southern Province Provincial profile - Uva Province Provincial profile - Western Province Conclusions and recommendations..6 References...9 Annexure...xviii Page xiv

15 LIST OF TABLES Table : Health status indicators Table 2 : Available personnel per, population Table 3 :Prevalence of underweight 993, 2, 26/7 DHS survey data... 8 Table 4: Nutritional Status among school children... Table 5: Number and categories of personnel interviewed at the national level Table 6: Number of stakeholders included at sub national levels, by categories Table 7: Contributions to support the scaling up of nutrition action by national level stakeholders... 3 Table 8: Specific contributions to support scaling up nutrition activities by province Table 9 : Policies related to nutrition at the national level Table : Actions taken by different districts in enforcing the International of Marketing of Breast-milk Substitutes Table : Status of BFHI certification by province Table 2: External sources of funding by province, as informed by district level managers Table 3: Funds used by donors for nutrition activities for the year Table 4 : Government sectors involved at district level Table 5 : Coordination mechanisms at district level Table 6: Support and supervision as reported by district managers Table 7: Study of available information indicate the wide inter district variations in the number of staff involved in nutrition programmes Table 8 : Number of provinces that reporting training made available, by staff category... 6 Table 9 : Number of districts that have conducted training programmes by topics... 6 Table 2: Number of districts that undertake follow up training activities... 6 Table 2 : Training and percentage distribution of trained PHM Page xv

16 Table 22 :Availability of training material in local language for MOH, PHNS and SPHM Table 23 : Number of facilities where nutrition programme materials were available Table 24: Responses from facility mangers on availability of a system for follow up Table 25: Method of follow up Table 26: Health workers by province/ district who have correct knowledge of nutrition protocols Table 27: Health workers by district/ province who feel confident to address activities relevant to nutrition programmes... 7 Table 28 :Frequency of counseling a mother with breastfeeding difficulties by PHMs... 7 Table 29 : Nutrition education and places where counseling is carried out Table 3 - Sources of technical support for health workers Table 3 : Summary of the information on nutrition indicators, use of data and receipt of feedback and the use of feedback, by district Table 32: Availability of adequate stocks of drugs Table 33: Date of expiry of available drugs/ supplements Table 34: Availability of facilities for taking anthropometric measurements Table 35: Availability of IEC materials at facility level... 8 Table 36: Community based activities undertaken by the MOHs, by province Table 37: Opinion to get better community support in breastfeeding Table 38: Other community mobilization programmes that MOH staff has participated., in the areas where facility visits were made Table 39: Presence of community nutrition programmes at the clinics of the local community PHM 87 Table 4: Presence of breast feeding support groups or volunteers based at the clinic or the community Table 4: Frequency of meeting breast feeding support groups or volunteers Table 42: summary of the main findings of the indepth country assessment Page xvi

17 Annexure Table A : Major nutrition Problems mentioned by national level stakeholders... XVIII Table B : Major causes mentioned by national level stakeholders... XVIII Table 2 Table 3 Table 4 Table 5 Table 7 :Data from sub national level of reported activities in facilities may complement... XIX :Nutritional Activities in current district action plan.... XXI :Status of BFHI certification in the provinces and districts:... XXII :Health workers assessment about relevance of training to job:... XXIII :Facilities with adequate level of stocks of drugs.... XXIV Page xvii

18 LIST OF FIGURES Figure : Map of Sri Lanka showing provinces and districts Figure 2 : Organizational structure for provision of preventive and promotive services relvent to nutrition ( state health services)... 6 Figure 3: Trends in under nutrition among under-five children in Sri Lanka... 8 Figure 4: UNICEF conceptual framework - Relation between basic, underlining and immediate causes of maternal and child under nutrition (UNICEF 99)... 6 Figure 5: Twelve Policy Statements Included in National Nutrition Policy Figure 6 :Interventions provided for pregnant women Figure 7: Interventions provided for children up to 5 years Figure 8: Stakeholder mapping Interventions for nutrition Page xviii

19 EXECUTIVE SUMMARY Sri Lanka has shown significant improvements in maternal and child health indicators during the past few decades. However, indicators related to nutritional status have not shown comparable improvements with maternal and child under nutrition. Therefore it still remains as a significant public health problem. In Sri Lanka, provision of health care to the population is mainly delivered by the state. Health services are provided free of charge to the recipient and includes a wide array of programmes focusing both on preventive and curative health care. The preventive services being more focused on maternal and child health services, which has significant inputs in nutrition. Landscape analysis to identify the readiness to accelerate actions on reduction of maternal and child undernutrition was undertaken in Sri Lanka. It aimed at identifying critical health system constraints for scaling up nutrition-related activities, engaging with key policy makers and senior managers by analysing the capacity gaps hindering the optimal scaling up of nutrition-related activities, to make strategic, relevant and specific recommendations to the national plans of actions in the scaling up of nutrition-related activities and to build the capacity of national, provincial and district personnel in the conduct of a detailed nutrition programmatic assessment by participating in this process. The study included three parts; Part one, focusing on a desk review of the current nutrition situation in the country along with the interventions that are on going; Part two, an in depth country assessment and Part three, development of provincial profiles summarising the nutritional status indicators and their determinants, identifying programme related issues at the provincial level identified during the in depth country assessment. A descriptive study aimed at obtaining relevant information at the different levels of the health system, central, provincial, district, divisional and field levels, using a series of study instruments developed by WHO with appropriate country specific modifications was carried out. At the national level, stakeholders in the health sector and the non health sector were included and semi structured interviews were conducted to obtain the information. Eight out of the total of 9 Provincial Directors were included and in addition the Chief Secretaries of the provinces, who are the main financial authorities at the provincial level were also interviewed. At the district level, the Regional Director of Health Services (RDHS) and the Medical Officer Maternal and Child Health ( MOMCH ) were interviewed and a similar method was adopted in obtaining information from the Medical Officers of Health (MOHs) at the divisional level where visits were made. Rest of the MOHs were sent the self administered questionnaires.colombo Municipal Council (CMC) area is administered by the Page xix

20 Municipal council and has its own staff and the Chief Medical Officer (CMOH) of the CMC was also included. A two stage stratified sample of field level service facilities were identified.trained investigators visited these facilities to make observations using a checklist and interviews were conducted with the field level service personnel (PHMs) and the facility managers ( PHNSs, SPHMs,SPHIs). The other groups interviewed were representatives from donor agencies and from national level NGOs. Commitment at the highest political level is well demonstrated. A majority of national and provincial level stakeholders identified the common nutritional problems and their causes. Lack of coordination within the health sector and between health sector and other sectors, limitations in resources, both financial and human and poor targeting of interventions were the perceived barriers for scaling up nutrition actions as identified by both health and non health sector national level stakeholders. Contributions that the stakeholders could make to support the scaling up of nutrition action ranged from policy development to capacity building, conducting research and developing interventions for Moderate Acute Undernutrion (MAM). Improving general awareness, changing behaviour and better inter sectoral coordination were among the others. A majority of national level stakeholders were satisfied with national nutrition policy, though less so among provincial stakeholders. Integration of nutrition interventions into the MCH package implemented at all levels of the health system indicated that programmes proposed in the policy being practiced at all levels. Nutrition related activities have been incorporated into programmes in the education, agriculture and social and economic development sectors to some extent. Main funding source for nutrition programme is the state with some external sources of funding. n availability of a budget line for nutrition in the health budget is noteworthy. Coordination activities are present at the highest political level as well as at the Ministry of Health at national, provincial, district and divisional levels. Even though involvement of other sectors also have been reported, such collaboration needs strengthening. NGO sector involvement is limited and is linked with provision of services. Personnel in the health sector at all levels are the key providers of nutrition related services hence there is no separate category of nutrition staff.in addition to the basic training, many categories of staff receive in service training in nutrition related areas, either locally or on a limited scale, overseas. Training opportunities are linked with the programmes. A majority of field level health staff considered the training to be relevant to their job functions and indicated the need for more training in selected areas. Training materials on selected aspects related to nutrition are prepared at the national level even though availability of such materials at the field level needs improvement. Page xx

21 Health worker s knowledge was satisfactory except in selected areas, in growth monitoring and promotion, management of severe or moderate malnutrition and breastfeeding in the context of HIV/AIDS. Nutrition education and counselling take place in different settings, ranging from clinics, to school medical inspections to the community. There were no major variations between districts/ provinces except for the observation that such activities are least frequent in CMC area. A broad based nutrition policy is required to include other key sectors and strategic plans need to be developed focusing on the contributions to be made by each Ministry. An effective mechanism to improve coordination within the health sector and between health and other sectors need to be developed. All sub national level plans should include nutrition as a component and to use all available data at each level to develop such plans - evidence based planning. For this to happen, timely availability of good quality information and developing planning capabilities at sub national levels are necessary. There is a need to streamline availability of guidelines, availability of drugs, appropriate IEC materials and other requirements at all service outlets. Community empowerment programmes to be implemented focusing on improvement of health and nutrition. Allocation of funds for nutrition related activities need to be streamlined specially in the health sector and may be necessary to consider a separate budget line for finances related to nutrition activities. Wide variations are seen between provinces/districts in policy and programme related issues pertaining to nutrition. Page xxi

22 PART I Background.. Sri Lanka Country profile Sri Lanka is an island situated in the Indian Ocean, off the southern coast of India, with a land area of approximately 62,75 square kilometers. The estimated population for 2 is 2,653 million with a population density of 326 persons per square kilometer (Central Bank of Sri Lanka, 2). Sri Lanka has a parliamentary democratic system of government, where the executive authority is exercised by a Cabinet of Ministers, presided over by an Executive President. The President and the members of Parliament are elected directly by the people. For purposes of administration, the country is divided into 9 provinces, 25 districts (shown in figure )and 324 Divisional Secretary areas. The provincial administration is vested in the Provincial Councils. There has been a marked increase in the literacy rates among both sexes, over the past few decades. The overall literacy rates increased from 65.4 percent in 954 to 92.8% among males and 9% among females in 2. (Central Bank, 2). When considering the economical status of Sri lanka, the GNP per capita has increased from US Dollars 556 in 992 to 2,29 in 29 with the GDP being US $253 in 29. Contributions made to the Gross Domestic Product (GDP) was by agriculture (2%), Industry (28.6%) and Services (59.3%). Poverty head count index showed a decline from a value of 28.8 in 995/96 to 5.2 in 26/7 to 7.6 in 2 (Department of Census and Statistics, 2 and Economic and Social Satistics 2). Page

23 Figure : Map of Sri Lanka showing provinces and districts..2.health status indicators Several of the commonly used health status indicators show improvements over the past few decades. The Infant Mortality Rate (IMR) show a declining trend throughout the past four decades, from 34 / live births in 98 and to.2 in 2 and an even lower figure of., estimated for 26. The contribution made by the neonatal deaths to the IMR has shows an increase from about 6% in 97 to 7 % in 2. The Child Mortality rate (number of deaths in children in the age group 4 year per children in that age group for the same year) shows a steady decline from 24.7 in 95 to 2.8 in 98 and to 3.4 in 22 (Ministry of Health, 27). Page 2

24 Table : Health status indicators Indicator Year Source Life expectancy at birth Total Female Dept. of Census and Statistics AHB 27 Male Infant Mortality rate Per/ live births Under 5 MR per under 5 population 2-26 Maternal Mortality rate per, live births Low birth weight babies per live births in government hospitals % of live births in a health facility % of pregnant women attended by trained personnel % of children under 5 years Underweight Acute undernutrition Chronic undernutrition Immunization coverage DPT3/OPV3 to infants Registrar General s Dept reported in Central Bank Annual Report DHS 26/ Annual Report on Family Health, Sri Lanka Medical Statistics Unit % Demographic and Health Survey 26/ % Demographic and Health Survey 26/ NFSS /7 97.% Demographic and Health Survey 26/7. BCG Measles OPV / DT at 5 years Women in the child bearing age using contraceptives Modern method Traditional methods 26/ Demographic and Health Survey 26/7. Page 3

25 An upward trend in the life expectancy is shown from 6.9 years for males and 6.4 years for females in 963 to 7.3 for males and 77.9 for females in 27. The rapid increase in the life span and the higher values for life expectancy seen among females compared to males indicate the improved survival rates among the groups that were more at risk such as women in the child bearing age group, infants, and preschool children. The successive Demographic and Health surveys show a consistent decline in the fertility rates from a total fertility rate of 2.8 during the period to.9 during the period with a marginal increase reported in 26/7 of 2.3. (Department of Census and Statistics, 28)..3. Health Services in Sri Lanka Organization for provision of Public Health Services The Ministry of Health (Central Government) is primarily responsible for the provision of comprehensive health services which include services for preventive, promotive, curative and rehabilitative care. At the central level, the responsibility for policy development, planning, and monitoring of the public health services is with the DGHS and the DDGPHS. There are nine provincial ministries of health and an equal number of Provincial Directors of Health services responsible for planning, implementation and monitoring of all health programmes including PH programmes, within the province. The decentralized units at the level of the central government have to liaise with the provincial health authorities and the provincial health care system. At the district level, a Regional Director of Health Services (RDHS) is responsible for management and effective implementation of all health services.in 2, there were 26 such officers.the key officers who are responsible for PH services at this level are: Medical Officer-Maternal and Child Health (MOMCH) responsible for implementation and monitoring of MCH and Family Planning services, Regional Epidemiologist responsible for disease surveillance and prevention of communicable diseases, Health Education Officer responsible for educational and health promotional activities and a Medical officer Planning to develop annual plans. In addition, there are officers responsible for supervision of PH services implemented at the divisional level e.g. Supervising Public Health Nursing Sisters, Supervising Public Health Inspectors.(Information are presented in figure 2) Page 4

26 Within each district, there are several divisions, each in charge of a Medical Officer of Health (MOH). These areas which are geographically defined and have a defined population and could be considered as equivalent to the health units introduced in 926. In 27, there were a total of 324 such units spread throughout the island (Ministry of Health, 27) Each MOH area has several PHM areas with the Public Health Midwife (PHM) as the grass root level health worker, responsible for the preventive and promotive health services for a population of approximately 3 4 residing in a geographically defined area, focusing on family health activities. The immediate supervising officers, Supervising Public Health Midwife (SPHM) and Public Health Nursing Sister have an important role to play in monitoring service provision. Nutrition has been an integral component of the maternal and child health services. These services are provided at the divisional level, through the MOH and health staff PHNS, PHI, PHMs. In some health units, there are Supervising PHIs (SPHI) and Supervising PHMs (SPHMs). Services are provided through clinics established at the field level and at domiciliary level. Available personnel per, populations are given in table2.there are wide inter-district variations in the availability of personnel. Activities aimed at promoting nutritional status and preventing undernutrition are undertaken mainly through the field based services described above. The organizational structure for provision of such services that focus on nutrition is shown in Figure 2. Treatment facilites required for nutrition related clinical situations, mainly severe acute malnutrition are provided through the institutional services which come under the purview of the same Ministry. Table 2 : Available personnel per, population - 27 Category of personnel Number Rate /, population Medical Officers (all), Medical Officers (MOHs) Public Health Nursing Sisters 29.4 Public Health Inspectors, Public Health Midwives 6, Source: Annual Health Statistics, 27, Medical Statistics Unit, Department of Health, Ministry of Health Care and Nutrition, Sri Lanka) Page 5

27 At the Central Level At the Provincial Level Minister of Health Provincial Minister of Health Secretary Provincial Secretary (Health Services) Director General of Health Services PDHS Deputy PDHS DDG- Level PHS I & II DDG- ET & R DDG - MS District RDHS/MOMCH Director- Nutrition division Director- MCH Director- Nutrition coordination Director-MRI Department of Nutriton Director-NCD SPHI PHI Divisional Medical Officer of Health PHNS SPHM PHM Field staff- A.M.C./A.F. Plannin g Assist. Director-Est. and Ur.Health Director - E& OH Director-HEB Figure 2 : Organizational structure for provision of preventive and promotive services relvent to nutrition ( state health services) Page 6

28 Main activities related to maternal and child nutrition undertaken at the divisional level ( by the MOH and field staff) could be broadly grouped as follows: Maintenance of maternal and child nutrition information of the area Disease surveillance and activities related to prevention of communicable diseases e.g. immunization. MCH services including nutrition and FP services School health services including nutrition screening Environment and occupational health Food hygiene Health education and health promotion Implementation of special programmes aimed at promoting health at the community level Financing of health care services Provision of free health services to the population of Sri Lanka was one of the important welfare measures that have been in existence in Sri Lanka since independence along with the system of free education. Available data indicate that in 27, the state spent 4.9 % of the total national expenditure on health which amounted to.22% of the GNP.( Annual Health Statistics, 27, Medical Statistics Unit, Department of Health, Ministry of Health Care and Nutrition, Sri Lanka) Available information indicates that.8% of the total national budget is spent on national nutrition programmes. However, it is not clear as to what activities this amount is spent for. Role of n Governmental Organizations (NGOs) ngovernmental organizations too play a limited role in public health services except in the area of family planning. There is one local NGO which has countrywide inputs related to health promotion and prevention activities including nutrition. They too have linkages with the state sector health system which provides support in many of their activities. Page 7

29 .4. An overview of the nutrition situation in Sri Lanka Nutritional status and determinants Maternal and child under nutrition remains major public health problems in Sri Lanka, despite improvements in many health indicators. Assessment of nutritional status has been carried out periodically as a part of the Demographic and Health Survey 26/7 conducted by the Department of Census and Statistics. Data from the DHS and other nutritional status surveys carried out from to 29, show a decline in stunting over the past five decades with no major changes in the prevalence of wasting. (Figure 3) wasting stunting Underweight (Source: MRI 975,77, 98, 995,29 and DHS 987,2,26) Figure 3: Trends in under nutrition among under-five children in Sri Lanka The MDG Report 29 presents a detailed analysis of prevalence of underweight among children less than 5 years of age using DHS data. These comparisons show an overall decline in the prevalence with the percentage decline between 993 and 26/7 in each sector being in the range of %, showing lowest decline in the estate sector and the highest decline in the rural sector. (Table 3). Table 3 :Prevalence of underweight 993, 2, 26/7,29 DHS survey and MRI survey data /7 29 % decline between993 29/ Sri Lanka* Urban Rural Estate *Values based on WHO standard Page 8

30 The findings of the two most recently conducted large scale sample surveys where nutritional status was assessed are presented to show the current status in Sri Lanka. They are: DHS conduced in 26/27 on a sample of 9,862 households in 2 districts out of 25 districts in Sri Lanka and the Nutrition and Food Security Survey (NFSS) conducted in 29 which included 67 households from study areas in 9 provinces (one district per province) along with the Colombo Municipal Council area, considered as a separate study area. Low birth weight (LBW): The newborns with a birth weight of less than 25 grams as being low birth weight (LBW) were considered as low birth weight (LBW). The relatively high proportion of newborns being LBW has continued to be a problem in Sri Lanka even though there is a marginal decline seen at a national level, from 7% in 22 to 6.6 % in 26/7 based on DHS. The data were available for surviving children and obtained the information from the CHDR s as far as possible. The incidence of LBW in the estate sector has increased from 2% to 3% between the two DHS (26/7). The percentage of LBW reported in the NFSS (2) was 8.%. Marked variations by sector shows that the prevalence in the estate sector (38.3%) is nearly double that of urban (5.7%) and rural (6.8%) sectors. In the NFSS (Ministry of Health, 2), the birth weights were obtained from the Child Health Development Records (CHDRs) of all children born within the 5 years preceding the survey. The overall prevalence was 8. percent. Birth weight distribution by the current age of the child enabled comparison of prevalence of LBW among different birth cohorts. There is no definite pattern observed except that the cohort aged between months at the time of the study had the highest prevalence of LBW of 2. percent. Nutritional status of infants and children under five years of age According to repeated DHS, from 987 to 26/7, there is a reduction in the prevalence of chronic under nutrition (stunting) among children under five years in all sectors and in both sexes, the overall prevalence being 27.2 % in 987 to 8. % in 2. DHS 26/7 reported that 7.3% of the preschool children were stunted with 4%, being severely stunted. Stunting levels increased with increasing age, the highest percentage of 23% being seen in Page 9

31 the 8-23 month age group. Levels were higher for boys than girls and for the estate sector compared to urban and rural children. Disaggregating data by age group shows that the stunting prevalence has doubled from 6 months to 2 months and from 2 to 24 months. The prevalence rate for stunting does not appear to change much from 24 to 36 months. Inter district variations were marked with the prevalence in Colombo district being as low as 8.4% and showing a high prevalence of 4% in Nuwara Eliya district. Children of mothers with some secondary education were less likely to be stunted compared to those with only primary education. The prevalence of acute under nutrition (wasting) was shown to be 5 % among this group, with 3 % of them being severely wasted. Wasting prevalence was highest in the age group months and lowest in the 6 8 month age group Inter district variations were seen in the prevalence with the highest values reported from Trincomalee district (28 %) and in Hambantota district (9%).Children in Nuwara eliya district showed a lower levels of wasting even though the prevalence of stunting was much higher comparatively., most likely the children who are short are less likely to have lower weight for height ratios. The same survey shows that 2% of children in this age group were underweight and 4% were severely underweight, and the percentage increasing with age. Results of the NFSS showed that among all children in the age group 59 months, 9.2 % were stunted,.7 % wasted and 2.6 % were underweight. Severe stunting was seen among 4.6 % of the total group, with the comparable figures for severe wasting and severe underweight being.9% and 3.9 % respectively. Children with weight for height values more than +2 SD were considered to be overweight and this percentage was.9 %. Prevalence of severe stunting, was highest in the fourth year of life (6.4 percent), among males (5.2 percent), markedly higher in the estate sector (5.4 percent). Regarding severe wasting, the prevalence was high in the first 6 months of life, in the estate sector, in Colombo and Nuwara Eliya districts. Page

32 There is no significant difference in under nutrition between female and male children. There is, however, marked variations in prevalence across provinces. The Western Province shows the lowest prevalence of under nutrition. The Uva province has the highest incidence of underweight and stunting and second highest for wasting. Although a number of small and ad hoc studies conducted in the rth East do not permit any kind of generalization of the nutrition condition of the children in these areas, Demographic Survey conducted in 2 showed that the underweight percentage of the child population in conflict affected areas was higher than the rest of the country by 5 percentage points School children. Available data indicate that stunting and wasting among the primary schoolchildren have been declining during over the past decades, i.e. 7.3% and 3.9% respectively in the year 22. Still the situation is unsatisfactory (Pathmeswaran et al. 25) Data on the nutritional status among school children aged 5 8 years between 23 and 2 based on surveys carried out in schools are presented in table 4 (Jayatissa et al.2 a) This comparison shows a reduction in the prevalence stunting, wasting and obesity with an increase in the prevalence of over weight. Table 4: Nutritional Status among school children Nutritional status prevalence Stunting Wasting Overweight Obese.8.5 Source: Jayatissa et al.2 A study conducted among a nationally representative sample of 6,264children, adolescents, aged between -5 years reported prevalence rates of underweight, stnting and overweight were 47.2%,28.5% and 2.2% respectively (Jaytissa et al.26 a). Prevalence of anaemia and Page

33 vitamin A deficiency ( as identified by the presence of Bitot s spots) were.% and.4% respectively (Jaytissa et al.26 b) A study conducted among,224 children aged between 8-2 years in seven schools on the city of Colombo reported that 24.7% of boys and 23.% of girls were thin, 5.. % of boys and 5.2% of girls were stunted and 7.% of boys and 6.8% of girls were underweight. At the other extreme were the 4.3% of boys who were obese with the 3.3. % of girls being obese. It was observed that a majority of those who were obese belonged to the higher income groups (Wickramsinghe et al. 24). The higher prevalence of obesity seen in this study is most likely due to the selection of schools included in the study. Nutritional status of non pregnant women DHS 26 reports that among the non pregnant women in the age group 5-49 years, % were short, had height less than 45 cm. and 6% of women were thin (BMI less than 8.5), with % of them being mildly thin and 6% being moderately or severely thin. Moderate to severely thin be highest in the age group 5 9 years and among those in the estate sector. Prevalence of low stature and severe and moderate thinness decreased with improvement of educational status and wealth. Nearly one third (3%) of women were overweight or obese (BMI >25), the percentage increasing with increasing age. Even though only 7% of women were obese, urban women and those in the highest wealth quintile were more likely to be obese. Data from NFSS, reported on the assessment of the nutritional status of non pregnant women aged 5 4 years who had a child less than 5 years at the time of the survey. Of this group, 8.2% had BMI less than 8.5 (thin), 22.5% with values between 25 and 29 (overweight) and 6.7% with BMI values 3 or above (obese). Prevalence of underweight was high in the 5-9 age group (4.5%) with the percentage declining in the older age groups. The % of overweight and obese women increased with increasing age, this pattern being most marked after 3 years of age. Nutritional status among pregnant women Page 2

34 Information on weight gain during pregnancy is scanty. However, available data indicate that the average weight gain in pregnancy is less than 7.5 kg compared to a minimum of 9.5 kg for adequate birth weight and safe delivery. Nearly 8 per cent of women are undernourished (Jayatissa et al.2 B). Adults The prevalence of under weight among adult males (36.2% in the year 995) and females (25.8% in the year 22) were high, more marked in the estate sector. Overweight is present in about 6.4% of women and 9% of men. Prevalence of obesity is quite low for both sexes. However, the overweight and obese individuals are likely to increase in the future with an increased risk to chronic diseases like diabetes and coronary heart disease. Community based studies on nutritional status of elderly are limited. Jayakody( 22)carried out a study on a sample of 394 persons aged 6 and over, in a district of Sri Lanka (Matale). Prevalence of under nutrition according to BMI (Body Mass Index) in the estate, rural and urban sectors was 58.3%, 4.% and 22.3% respectively, with an overall prevalence of 38.4%. In all three sectors, females (4.3%) had a higher prevalence of obesity than males (7.3%). Prevalence of under nutrition among the elderly in the three sectors increased with advancing age. Among the significant risk factors for undernutrtion among rural elderly were : low income, low level of education, elderly who felt isolated and those who did not consume animal proteins, milk and milk producteds an fruits. Prevalence of over weight was higher (22.9%) among elderly in the urban sector. Micronutrient Deficiencies In Sri Lanka, three micronutrient deficiencies that have been identified as public health problems, namely, deficiencies of iron, vitamin A and iodine. Anaemia Iron deficiency anaemia continues to be an important public health problem in Sri Lanka, especially among women in the reproductive age group and children. A study carried out in 996 (Mudalige R, Nestle P, 996 prevalence of anaemia in Sri lanka, Ceylon Journal of medical science ) assessed on the prevalence of anaemia among children. 749 preschool children this study reported that the prevalence rates among infants aged 6- Page 3

35 months, children under five years of age and women ranged form 4-6%. According to Piyasena and Mahamittawa (23), in 2, the prevalence rates of anaemia among the children aged 6 months and those in the month age group was 57% and 5% respectively. This study also reports that between 996 and 2, anaemia prevalence increased in the age group 6- months with a decline shown in the other age groups. The same study included assessment of Hb levels on 2437 primary school children 5- years of age and a prevalence of 2.9% was observed, with no significant differences between males and females. The highest prevalence was seen in the urban sector (25%) compared to 2% and 4%in the rural and estate sectors respectively. The prevalence among adolescents identified as those aged between -8 years was 3%with a significantly higher prevalence among females (26%) compared to males (8%). The inter sectoral differences showed the same pattern as that among the primary school children, with the highest prevalence in the urban sector26% and lower values in the rural 2 and estate sectors. Findings of the NFSS (2) carried out in 29 showed the prevalence of anaemia among children under five years to be 25.2 % with the highest prevalence being in the latter half of infancy (5.4%). The prevalence decreases with increasing age with the lowest value reported among the children in the month age group (.2%).Inter sectoral differences does not show much variations with the urban sector reporting a marginally higher prevalence 26.7% compared to 25.2% and 24.7% in estate and rural sectors respectively. There was no consistent pattern seen in the prevalence with levels of maternal education and indicators of income and wealth. Anaemia among non pregnant women: Study by Piyasena and Mahamittawa (23) include a sample of 473 women in the 5-49 year age group. The overall prevalence rate was 32% with the rates ranging from 29 in the age group less than 9 years to 43 % in those 45+ years. The inter sectoral comparisons showed a different pattern in that thee highest prevalence was seen among the estate women (37% with the rates for rural and urban women being 3% and 3% respectively. NFSS showed that the prevalence of anaemia among pregnant women was 6.7% with that among lactating women and all non pregnant women being 2.5 % and 22.2% respectively. Comparisons between sub groups were based on small sample sizes, hence are not reported here. Iodine deficiency Page 4

36 The first large scale study on prevalence of goiter was carried out in 987 (Fernando et al,989) among school children aged between 5 2 years. This study reported an overall goiter prevalence rate of 8.8 %. In Sri Lanka, a national level salt iodization programme was introduced in 995 and has been in place since then. However, available data indicate that iodine deficiency continues to be a problem even though the extent and intensity of the problem has decreased. A study conducted by MRI in 2 2 among a national sample of school children 8 years of age, showed an overall prevalence of goiter rate was 2.9%. As the prevalence rates did not show a major difference between the two studies, there was more attention paid to the salt iodization programme. (Jayatissa et al,25) A survey carried out in 25 among school children aged 6- years, the prevalence of goiter showed a decline to a value less than 5% and the median urinary iodine level greater than ug/l in all provinces (MRI,26). Most recent data from the survey carried out in 2 / 2 showed that goiter rate was 4.4% among school children aged 6- years and the median urinary iodine level greater than ug/l in all provinces (Jaytissa et al, 2).. Vitamin A deficiency The earliest available information on Vitamin A deficiency (VAD) is from the first national nutritional status survey carried out in that showed the prevalence of Bitot s spots and night blindness of. % and.% respectively (Brink and Perera, 979). The survey carried out by the MRI in 996 showed that the prevalence of sub clinical VAD was 36.3% with clinical VAD less than.5 %.( MRI, 998). This survey also showed that the highest rates of sub clinical VAD were seen in the rth Central and Sabaragamuwa provinces. A clinic based study carried out in 2 out of 25 districts in Sri Lanka including 9 children in the age group 6 6 months showed that 29.3% of children in this age group has serum retinol levels <2 ug/dl with 2.3% having serum retinol levels less that ug/dl. Among the non pregnant women in the 5-49 years, the percentage of women with retinol levels <2 ug/dl was 4.9 %. These data indicate that vitamin A deficiency is still a public health problem in Sri Lanka.(MRI,26) The prevalence of anaemia among pregnant women was 6.7% with that among lactating women and all non pregnant women being 2.5 % and 22.2% respectively. Page 5

37 .5. Determinants of Malnutrition The complexity of the factors that influence nutritional status has been depicted in the causal analysis framework presented by UNICEF, 99. (Figure 4). This framework identifies immediate, underlying and basic causes. The immediate causes of malnutrition are inadequate food intake and/or disease, while underlying causes include household food insecurity, inadequate care for children and mothers, and a poor health and health care environment. Each of these, in turn, can be linked to household poverty which is influenced by factors such as unemployment, depreciating assets on one hand and increasing cost of food and other requirements. The political, economical and cultural factors would be the basic causes as illustrated in this framework. Much of the work aimed at assessing the determinants of under nutrition has focused on infants and young children. As reported in many studies in different countries, the focus has been on feeding practices, morbidities and child care practices as major influencing factors. Figure 4: UNICEF conceptual framework - Relation between basic, underlining and immediate causes of maternal and child under nutrition (UNICEF 99) Determinants of low birth weight Page 6

38 World Bank (27) identifies maternal underweight, low household wealth status and lower level of sanitation as indicated by the non availability of pipe borne water inside the house as factors that were shown to have an association with LBW. Health care during pregnancy did not show any association, which may be linked with the high level of coverage of antenatal and natal care services in Sri Lanka. NFSS report does not present an analysis of the determinants of LBW. Several studies have considered the important determinants of under nutrition among children in Sri Lanka. Based on nationwide 2 DHS data, the World Bank (27) assessed the potential causal factors using advanced regression models. Another such attempt was made in the Causal analysis carried out using DHS 2 data also reported similar findings (MRI, 26 ). The MDG report 28/29 also presents a detailed analysis related to the prevalence of under nutrition based on data from repeated DHS. A detailed analysis of the factors contributing to under nutrition in children aged 6-59 months as well as among women is presented in the NFSS (2). Some of the key findings from these assessments are presented in the sections to follow. Causal analysis carried out using the data from DHS 2 and UNICEF surveys on child welfare and health of 23 and 24 conducted in the 7 districts in the rthern Province. (MRI, 26)).Analysis of the DHS 2 dataset showed that low birth weight was the most significant predictor of stunting, wasting and underweight. A similar finding was reported from the analysis of UNICEF 24 data and UNICEF 23 data showed that falling below the respective birth weight band within the first two years was a significant predictor of under nutrition. Total number of children in the family was a significant predictor with those in larger families being more likely to be undernourished. Better maternal nutrition as indicated by the mother s BMI status makes a child belonging to such a family less likely to be undernourished. Socio economic status was a significant predictor of under nutrition. The analysis presented by World Bank (27) indicates the following.lbw is strongly associated with stunting and underweight and so are the children born to mothers who are underweight. Belonging to a wealthier household id associated with lower prevalence of stunting and underweight. Maternal schooling has an inverse relationship with underweight rates, for schooling level beyond GCE (OL). Sanitation, care practices and hygiene practices did not show any significant association. According to the MDG Report 28/29, low birth weight is more prevalent among poor and estate households and that nearly 23 per cent of babies born to mothers in the poorest income quintile were low birth weight. Page 7

39 MDG report 28/29 highlights the fact that malnutrition indicators exhibit considerable regional variations and identified the common correlates of malnutrition as: availability and utilization of health facilities, female literacy, good hygiene practices and health knowledge and insufficient access to food. Given that Sri Lanka has a high level of female literacy and a high level of use of health services, the likely reasons for the relatively high prevalence of malnutrition among the poor are insufficient access to food and exposure to unsafe sanitary conditions. The positive association between maternal schooling and child malnutrition is likely to be due to such factors as better knowledge and practices concerning childcare, feeding practices, environmental health, and household hygiene. Mother s schooling cans also proxy for higher socio-economic well-being of households over and above the effect of per capita consumption expenditure. Overall, the findings confirm the results documented in across a number of countries. Wasting was more prevalent among children in poor households, but not any higher for estate children than for rural children Child under nutrition NFSS report presents the determinants under broad groups as follows: Basic causes: Several socio demographic factors were shown to influence stunting and underweight as per the analysis carried out in the NFSS. One such factor was the inter district variations shown, with the prevalence of stunting higher in Nuwara Eliya and Badulla, wasting in the district of Colombo, underweight in NuwaraEliya and Ratnapura and anaemia in Jaffna. Increasing level of maternal and paternal education was associated with a lower prevalence of stunting and underweight and increasing family size and number of children under 5 years was predictive of a higher level of stunting. Significant declining trends were observed in the prevalence of stunting, wasting, underweight and anaemia with increasing wealth quintiles with increasing monthly household income was associated with lower rates of stunting and underweight. Underlying causes: Page 8

40 An increase in the expenditure on food as a percentage of total household expenditure was associated with an upward trend in the rate of stunting. Even though children in the food insecure households had a higher prevalence of stunting, wasting, underweight and anaemia, these differences were not statistically significant. Households with children who were stunted or underweight had a significantly low household dietary diversity score (HDDS). Dietary diversity score of children 6 23 months of age was significantly lower among stunted children. Children who visited child welfare clinics reported a significantly higher prevalence of underweight and higher but not significant prevalence of stunting and wasting. Households with poor larine facilities reported a significantly higher prevalence of stunting and underweight. Biological causes Children with LBW showed a significantly higher prevalence of stunting, wasting and underweight and these associations were present in studying mean birth weights. Prevalence of stunting was significantly higher during the fourth years of life and the prevalence of wasting and underweight from 2 nd to 5 th years. However, prevalence of anaemia showed a consistent decline with increasing age. There were declining trends in all four nutritional status indicators with increasing maternal BMI values. Determinants of under nutrition among women In depth analysis of the determinants of under nutrition among women were only available from the NFSS report. Findings from the multivariable analysis of factors associated with under nutrition in non pregnant women were age, increasing age being associated with lower risk of thinness and being in the estate sector indicated a fivefold risk of being thin. Thinness was less likely among women with higher family income level, higher wealth index and the husbands being educated to a higher educational level. Percentage of thin women was higher in households that spent more than 8% of their income on food. However, the differences were not statistically significant. The number of children in the food insecure group was limited. Page 9

41 Prevalence of overweight/ obesity was reported among non pregnant women and the factors that were associated with overweight/obesity were: lower risk among women in the estate sector. Belonging to higher wealth quintile and increasing level of husband s education were strong correlates for the risk of overweight / obese. PART II Page 2

42 In Depth Assessment The Department of Nutrition at the Medical Research Institute, Ministry of Health was the responsible body for conducting the Landscape Analysis. A Coordinating Committee was appointed by the Secretary, Ministry of Health to provide necessary guidance for the conduct of this activity. This Committee included all relevant senior officials from the Ministry of Health (Central Level), representatives from WHO, UNICEF, WFP and World Bank. A working committee was appointed to plan and carry out the work related to the Landscape Analysis in collaboration with the Coordinating Committee and a Consultant was selected to assist the working committee. The Working Committee met on a regular basis and undertook the planning of the study and its implementation. The steps followed during the planning stage were as follows: Review of study instruments provided by WHO and make appropriate revisions and finalize the tools Identify the detailed study design Presentation of the planned and study design and the study instruments, to the coordinating Committee and under their guidance, review, revise and finalize the study design and the study instruments Selection of study areas Recruitment of Research Assistants Attend to all field logistics required for implementation Training of field staff for data collection Implementation of the field based component Conduct of interviews 2.. Purposes of the Landscape Analysis assessment To develop a health systems-based conceptual framework to guide a review process that identifies bottlenecks and gaps to inform the scaling up of nutrition-related activities. To identify critical health system constraints necessary for scaling up nutrition-related activities. To engage with key policy makers and senior managers to identify key constraints and analyze the capacity gaps hindering the optimal scaling up of Nutrition-related activities. Page 2

43 To make strategic, relevant and specific recommendations to the national plans of actions in the scaling up of Nutrition-related activities. To build the capacity of national, provincial and district nutrition personnel in the conduct of a detailed programmatic assessment by participating in this process. 2.. Study instruments A total of eight study instruments were used in this study. Form National level stakeholders (within and outside the health sector) - Semi structured interviews for government agencies and other stakeholders at national level (Annex 6A) Form 2 Provincial level stakeholders- Semi structured interviews (Annex 6B) Form 3 District level staff Self administered questionnaires (Annex 6C) Form 4 Form 5 Form 6 Divisional level staff and Facility managers Self administered questionnaire (Annex 6D) Facility checklist (Annex 6E) Format for observations Health workers Semi structured interviews for all clinic staff available at the time of the visit (Annex 6F) Form 7 NGO Managers (Annex 6G) Form 8 NGO Nutrition programme Coordinators (Annex 6H) (Copies of all study instruments are given in Annexure 2) 2.3. Methodology Page 22

44 A descriptive study aimed at obtaining relevant information at the different levels of the health system was carried out during the period of mid March April 2. Institutions/ departments outside the health sector were identified and included in the study as relevant. National level stakeholders (health sector): This group including 2 key personnel was identified in consultation with the Coordinating Committee. The list of persons is given in annex. Semi structured interviews were held with all these stakeholders using Form. National level stakeholders (outside the health sector): A similar approach was used to identify the key stakeholders (5) outside the health sector and the same procedure was used in collecting relevant information from this group of personnel, using the Form. Provincial level: Provincial Directors of Health Services (PDHS), each in charge of health services of each of the 9 provinces in Sri Lanka and six out of nine Chief Secretaries of the provinces who are responsible for overall planning and financial management of all programmes within a province were also included. Semi structured interviews were conducted using Form 2. District level: At the level of each of the 25 districts in Sri Lanka, the responsibility for provision of health services is held by the Regional Director of Health Services(RDHS) and the Medical Officer - Maternal and Child Health ( MO MCH ) responsible for planning and implementation of all maternal and child health related programmes including nutrition, within the district. Both these categories of health officials are key stakeholders at the district level and were identified for inclusion in the study. Self administered questionnaires (Form 3) were sent to each RDHS and MO MCH with a covering letter explaining the purpose of the study and seeking their cooperation. Divisional level Page 23

45 At the time of the study, there were a total of 39 Medical Officers of Health (MOH) areas with one or more Medical Officers serving as officers responsible for planning and implementation of all preventive health activities (including nutrition) within the area. All MOHs were sent a self administered questionnaire (Form 4) along with a covering letter. Colombo Municipal Council (CMC) Area is administered by the CMC and has its own staff. The Chief Medical Officer of the CMC was also included in this component of the study. Facility survey The field level health services focusing on maternal and child health delivered through the MOH and staff are provided through a series of field level clinics. These clinics may be Child Welfare Clinics, Antenatal Clinics or Polyclinics where multiple services are provided. To identify the clinic facilities to be included in the study, the following sampling procedure was adopted. Each of the 9 provinces in Sri Lanka included 2 3 districts and each district has a variable number of MOH areas/health divisions. As the first stage of sampling, one district was randomly selected from each province and from each such selected district two MOH areas/ health divisions were randomly selected. This enabled identification of a total of 8 MOH areas/health divisions. From each such MOH area, 2 clinic facilities were randomly selected based on a listing of such clinics at the MOH level, thus including 36 clinic facilities in the study. The Facility Checklist (Form 5) was used to assess the availability of protocols on nutrition related activities, IEC materials, availability of drugs and other requirements for nutrition programmes and equipment for taking anthropometric measurements. Facility managers Public Health Nursing Sisters (PHNS), Supervising Public Health Inspectors (SPHI) and/or Supervising Public Health Midwives (SPHM) are the facility managers of the field based clinics. All such staff members who were responsible for the clinic facilities were included in the study. Interviews using structured questionnaires were used to collect data, for this component (Form 4). A total of 45 facility managers were interviewed, among whom 7 (38%) were PHNSs, 3(29%) were SPHIs and 5 (33%) were SPHMs. Field level health workers Page 24

46 The key category of health workers included in this component is the Public Health Midwives (PHMs) who are the main service providers at the facility level. From each facility, 2-4 PHMs were administered a structured questionnaire (Form 6) by a trained interviewer. As numbers varying from clinic to clinic, a total of 96 PHMs were interviewed. Donor agencies Five donor agencies that are involved with nutrition related activities were identified and the relevant personnel were interviewed using the form with some modifications. n Governmental Organizations (NGOs) In Sri Lanka there are a only a limited number of national level NGOs that are involved in nutrition related activities. The Manager of the NGO and the Nutrition Programs coordinators were included in the interviews. Data analysis Each form was perused on receipt and all forms relevant to a group were collected separately. The responses to each open ended question were reviewed and then coded appropriately. tes were taken of any responses that could be considered as outliers, which were minimal. All coded questionnaires were entered into data base developed using SPSS Statistic soft ware. Separate analysis was carried out for each group included in the study. Assessment at the political level was done on the basis of the available information and not based on the primary data collected. Page 25

47 2.4. Results As described above, several categories of stakeholders were included in the study. A total of 33 stakeholders at national level, comprising of 2 from the state health sector, 5 from the non health sectors and 7 from other organizations were included (Table 5 ). Table 5: Number and categories of personnel interviewed at the national level Categories of personnel Gov.Health Gov.n- Health Secretary/Add.Secretary Donors, academics, professional bodies etc. DG/DDG 4 Directors 2 Programme managers 4 Total Number of stakeholders included at provincial, district, divisional and facility level, by province is given in Table 6. All Provincial Directors of Health Services except for the PDHS in the rthern Province were included along with 6 out of the 9 Provincial Secretaries. Colombo Municipal Council area though within the Western Province has a separate health services structure under the administration of a Chief Medical Officer of Health (CMOH) and does not come under the purview of the Ministry of Health at the central or provincial level. Page 26

48 Table 6: Number of stakeholders included at sub national levels, by categories Level Provincial District Divisional Facility Province PDHS PCS RDHS MOMCH MOH Facility managers (PHNS,SPHM, SPHI) PHM of facilities observed Western CMC* Central Southern rthern Eastern rth Western rth Central Uva Sabaragamuva Total * Colombo Municipal Council area Findings of the study are presented under two broad headings:. Commitment to act 2. Capacity to act. Page 27

49 2.4.. Commitment to act Political commitment Over the past decades during which time, when nutritional problems have been identified as important public health problems, political commitment to take action has been manifested in many ways. The policies and programmes that were undertaken to improve nutritional status have focused on three areas: direct food assistance programmes, poverty reduction programmes and the provision of an integrated nutrition intervention programmes through the maternal and child health programme of the Ministry of Health. The programmes that have been undertaken in the recent decades have been briefly described in the section IV of the overview of the nutrition situation in Sri Lanka. Political commitment at the present time is identified in the government development policy as enunciated in the Mahinda Chinthana - the way forward. Action has been taken by His Excellency the President, in 2 to establish a mechanism that will be responsible for policy development, programme planning and for provision of technical guidance to address the issues related to nutrition, clearly demonstrating the commitment at the highest political level. This mechanism included the appointment of the National Nutrition Council (NNC), National Steering Committee on Nutrition (NSCN), the Technical Advisory Committee (TAC) and Presidential Task force on Food security.. The National Nutrition Council: This Council is chaired by HE the President and comprises of 5 Ministers including all those who have a direct or indirect link with the notional status of the population o Sri Lanka. National Steering Committee on Nutrition (NSCN) is chaired by the Secretary to HE the President, and includes Secretaries of 4 key Ministries and 4 others with technical and administrative experience in related fields. Members of 5 international agencies active in nutrition related work are included as observers. The Technical Advisory Committee includes technically competent persons, in nutrition related fields. All above information highlights that nutrition has been considered as a component of development programmes at national level. Page 28

50 Awareness of nutrition problems and underlying causes among stakeholders Most of the stakeholders at the provincial and national levels identified the common nutritional problems, a majority identifying anaemia, malnutrition, Vitamin A deficiency and micronutrient deficiencies. More than a third mentioned obesity and NCDs as growing problems. However, only a limited number mentioned maternal under nutrition and low birth weight as important problems. Lack of awareness in the community was identified as a cause for nutritional problems by most of the health and non health stakeholders with other causes such as poor access to food, bad food habits, cultural factors and poverty being among the other causes mentioned. Details are given in Annuxure 3, Table A and B. A majority were of the view that food prices affect nutritional status of the poorest, urban and estate sector. The two main coping strategies identified by the stakeholders were reducing quantity and quality of food. These strategies indicate the direction that is required to support the community, during periods of food price escalation. Some of the actions that could be taken by the state has also been identified.they include actions to be taken by the state to control food prices and strengthen the price control system and reduction of taxes. Promoting home gardening has also been mentioned Willingness of partners to contribute to scaling-up of nutrition actions Perceived barriers for scaling up of nutrition actions Lack of coordination within the health sector and between health sector and other sectors, limitations in resources of financial and human and poor targeting of interventions were the key factors identified by both health and non health sector national level stakeholders. The main barriers identified include: nutrition not being considered a priority and poor accessibility. Adverse inputs from media ( specially related to food advertising) were considered as a factor by the non health sector. Provincial level staff has also identified inadequate financial and human resources, nutrition not being considered a priority; poor inter sectoral coordination and inadequate training as important factors. Page 29

51 Commitments of stakeholders to scale up nutrition action Identification of different interventions for scaling up nutrition was inquired into from national and provincial level stakeholders. Both these groups (in the health and non health sectors) identified similar interventions. Accordingly, the top priority needs at both national and provincial level were identified to be: Human resources, financial resources and Training National level stakeholders mentioned a series of specific contributions that they could make to support the scaling up of nutrition action. These are given in Table 7. The contributions identified by different stakeholders include several activities with some degree of overlap. The actions suggested by the Ministry of Health ranges from policy development to capacity building, conducting research and developing interventions for MAM. Improving general awareness, changing food related behaviour and better inter sectoral coordination, supporting evidence based nutrition interventions, were among the others. In addition to the above, donors suggested actions such as implementation of village micro plan concept to empower the families, implementing a good social marketing campaign and to provide comprehensive support and technical assistance to strengthen the government to address malnutrition Page 3

52 Table 7: Contributions to support the scaling up of nutrition action by national level stakeholders Stakeholder Ministry of health Ministry of Agriculture Ministry of Child Development & Women s Affairs Ministry of Education SLMA Faculty of Medicine UNICEF WFP World Bank WHO Action Develop intervention for MAM Capacity building Formulation of correct policy,iodine deficiency control programme, monitoring and evaluation Conduct research Improve general awareness Change parents incorrect food behaviour Empowerment of students Better inter-sectoral coordination Research, training Implementation of village micro plan concept to empower the families, strengthen inter-sectoral collaboration Management of MAM Good social marketing campaign, provide comprehensive support and technical assistance to strengthen the government to address malnutrition. Help to plan nutrition interventions based on evidence Information on the specific contributions that could be made by provincial level stakeholders is given in table 8. Health education, improving inter sectoral coordination and monitoring and evaluation were among the suggestions. Three provinces claimed to be ready to contribute to increased fund allocation for nutrition (Table 8). Page 3

53 Fund allocation Monitoring and evaluation Provide training Inter Sectoral coordinatio Health education Table 8: Specific contributions to support scaling up nutrition activities by province Central Eastern rth central rth western thern Province Sabaragamuwa Southern Uva Western Mentioned by how many provinces Page 32

54 Focused policies and regulations at central level with supporting plans and protocols at the sub national levels Specific and appropriate nutrition policies, strategies and actions plans at the central level The national nutrition policy is linked with a workable strategic plan, and was gazetted in February 28. This document identified the key health related and non health interventions aimed at improving nutritional status. The document included the goal, objectives and 2 policy statements and the strategies related to each such statement and focuses on a number of nutrition interventions (Figure 5) that are feasible and relevant. A majority of national level stakeholders seem to be satisfied with national nutrition policy (though less so among donors). Some shortcomings are also identified. Among the positive features identified were: use of life cycle approach, identifies poor lifestyle as a problems leading to malnutrition, reflects the Ministry of Health commitment to act on nutrition problems, outlines the responsibilities of the stakeholders and constitutes an authoritative basis for action. This document also indicates the keen interest to start action and identified the need to have programmes to implement the policy. Some of the shortcomings identified were: inadequacies of the policy regarding food security, need for coordination and the need for a more intensive national programme with a multi sectoral approach. Page 33

55 Fortification, genetically modified food Nutrition promotion among mothers and children<5yr Nutrition promotion among school children Advertising And marketing Food and nutrition education Consumption of processed food National Nutrition Policy Completed in 2 Research Food safety Patient nutrition care Reform common agricultural and fisheries policy Food security Nutritional Monitoring and surveillance Figure 5: Twelve Policy Statements Included in National Nutrition Policy Page 34

56 In addition to the National Nutrition Policy, there are several other policy/related documents which have an implication on nutrition. They are listed below and they were reported by Sri Lanka to the Global Nutrition Policy Review. Table 9 : Policies related to nutrition at the national level Title Published Year Institution National Nutrition Policy 28 Ministry of Health (D/NCU) National Agriculture Policy 27 Ministry of Agriculture and Agrarian Services National Livestock Development Policy and Strategies National Fisheries and Aquatic Resources Policy Maternal and Child Health(draft) Health Promotion Policy(draft) 26 Ministry of Livestock and Infrastructure Development 26 Ministry of Fisheries and Aquatic Resources Ministry of Health (D/FHB) Health Education Bureau (MoH) School Canteen Policy 27 Ministry of Health (D/HEB) Policy for Disabled 23 Ministry of Social Development National Nutrition Strategic Plan 29 Ministry of Health (D/NCU) n Communicable Disease Policy 29 Ministry of Health (D/NCD) National policy and stratergic plan for young person.(draft) New "Samurdhi" Beneficiary Selection Policy (The National Poverty Alleviation Program) Ministry of Health (D/Y&ED) 2 Department of Commissioner general of Samurdhi Elders Policy 25 Ministry of Social Development Page 35

57 Views of stakeholders on nutrition policies Among the issues raised by the national level stakeholders were: implementation of the policy is at low level, more multi sectoral coordination required in implementation, practical application of the policy not adequate, inadequate emphasis on aspects related to food security. On the contrary, most ( out of 5) province level managers were not satisfied with nutrition policies. Issues mentioned included : lack of results of current policies in terms of reduced malnutrition, lack of funds and staff for implementation, lack of coordination at national and provincial level, need for a multi sectoral approach and inadequate attention to food security. Integration of nutrition into provincial and district level plans Integration of nutrition interventions into the MCH package implemented at all levels of the health system indicates the inclusion of the programmes proposed in the policy being a component of the package of intervention. Detailed information of the activities implemented at the district level is given in Annexure, Table 2. Activities at the provincial level mostly concern programme management, e.g. planning, monitoring and evaluation(m&e), logistics related to supplementation, coordination, nutrition assessment, etc. and those at district level deal mostly with all aspects of implementation of the programmes, M &E. The main nutrition related activities in the provincial plans include: planning programmes, monitoring, supplementation, staff training and coordination. The stakeholders in the non health sectors identified policy making as the main input in the nutrition plans at the provincial levels. These are in line with the key nutrition policies or plans. 23 out of 26 district managers mentioned that nutrition is part of district action plan. Most often mentioned activities at the district level were supplementation, health education, Nutrition rehabilitation programme (NRP) and school health nutrition. Seven out of 5 provincial level managers mentioned that provincial level policy in support of nutrition activities exists. Detailed information on nutrition related Activities in current district action plan are given in Annexure Table 3. Page 36

58 Incorporating nutrition into plans and programmes in the health sector The key programmes to which the nutrition activities have been integrated are the Maternal and Child Health (MCH) programme and the school health programme. Policy decisions are made at the level of the central Ministry of Health with the Family Health Bureau as the decentralised unit at the Ministry of Health responsible for these programmes. All programmes are planned and implemented in the provincial and the district health system, in keeping with the devolution of implementation of activities. A summary of the key activities carried out by the MCH services are given below: Provision of a package of antenatal care services to all pregnant women with a view to reducing under nutrition and micronutrient deficiencies through food supplementation, micronutrient supplementation, monitoring weight gain in pregnancy, nutrition education and early detection and management of conditions that have a negative influence on birth weight of the newborn and promote institutional care at delivery Antenatal preparation for promotion of breast feeding Support for lactating women through education, supplementation Implementation of breastfeeding code and BFHI to promote optimal breast feeding Supportive activities towards proper complementary feeding Growth monitoring and promotion Use of Child Health Development Record (CHDR) Targeted food and micronutrient supplementation for children aged between 6 months to five years. Implement activities of the ECCD programme Accordingly, several interventions are included in the nutrition programmes at the district level. ( Refer Annexure Table 3). Monitoring of MCH activities is undertaken at all levels field level by supervisory visits, divisional (MOH) level at review meetings held monthly, district level through meetings of MOH with the RDHS and staff and at higher levels, through provision of information as a component of the reproductive health information system(rhis). All above programmes are implemented at the divisional level through the Medical Officer of Health and the field level health staff working at the field level. They include the Public Health Midwife, the field level health worker responsible for MCH activities including Page 37

59 nutrition for a defined population (approximately 3) residing in a geographically defined area. The services are provided through a field visits and through the health facilities (clinics) available at the field level. Those implemented through the school health programme include, school medical inspections, which include screening of school children, nutrient supplementation as required, environmental sanitation, focused education activities and promotion of child friendly schools concept where many health promotional activities are carried out. Thus, integration of nutrition into maternal and child health and school health programmes and protocols is mandatory. The draft MCH policy also includes these aspects. IMCI programmes include nutrition in a satisfactory manner in that the Training Manual for Management of sick children under 5 years, at primary care level includes a substantial component of nutrition. HIV programmes are within the preview of the National STD/AIDS Control Programme (NSACP) at the national level with activities implemented through the provincial and district level health staff. Training of health workers in relation to breast feeding by HIV positive mothers has been undertaken by the national programme responsible for training of trainers, with the contents being passed down to the field level health workers there onwards. Figure 6 and 7 present the summary of these interventions. Page 38

60 Supplementation for lactating mothers Food supplementation- Thriposha Post partum Vit. A megadose Iron,Folata,Calcium supplementation Institutional delivery care Monitoring of weight gain Figure 6 :Interventions provided for pregnant women Complementary feeding Exclusive Breastfeeding Household water treatment, Sanitation School Medical Inspection Vitamin A supplementation Forcused Health Education Deworming Local homestead food production Measles vaccination TargetedSupplementary feeding Promotion of Child friendly school Growth monitoring and promotion Targeted Micronutrients for children aged 6 months to 5 yrs Therapeutic feeding Iron supplementation Iodized salt Figure 7: Interventions provided for children up to 5 years Page 39