Multi-sectoral nutrition governance: Demystifying multi-sectoral nutrition actions

Multi-sectoral nutrition governance: Demystifying multi-sectoral nutrition actions Childhood Stunting Colloquium WHO, Geneva 14 October 2013

REACH is an inter-agency partnership that promotes a country-led, multi-sectoral approach to addressing undernutrition WHO? Inter-agency partnership initiated by FAO, WHO, UNICEF, WFP (plus IFAD) Partners from other UN agencies, the NGO community, academia, private sector and donors Support to SUN at country level and part of the UN network for the SUN Movement (REACH and SCN co-facilitate the UN network) International + national facilitators who facilitate inter-agency collaboration and SUN processes at country level REACH Secretariat, hosted by WFP Rome WHAT? A country-led process designed to improve nutrition governance A multi-stakeholder, multi-sectoral approach to tackling undernutrition Not an implementing agency! Intense support Moderate support Remote support Interested &/or emerging

It catalyses multi-sectoral collaboration between UN Agencies, governments and civil society to combat child undernutrition Multi-stakeholder platform Objective: Reduce child undernutrition Agriculture Donors Country government FP UN Agencies Civil Society Social Protection By 2015: Reach MDG 1, Target 1C: half the proportion of underweight children <5 Beyond 2015: Achieve sustainable acceleration of the rate of reduction of child undernutrition Sectors REACH contributes to the "UN delivering as One"

REACH applies a Theory of Change to accelerate progress towards MDG1, target 1C If we address these issues with these strategies to improve governance then we can achieve this impact Little consensus on the causal problems of undernutrition Limited political commitment Weak coordination of gov'ts with UN agencies and other stakeholders Nutrition is not seen as a multi-sectoral issue Poor capacity development Accountability and responsibility is undervalued REACH outcomes 1. Increased awareness and consensus of stakeholders 2. Strengthened national policies and programmes 3. Increased human and institutional capacity 4. Increased effectiveness and accountability Political support to fund programs and coordinated nutrition efforts Nutritional impact and coverage Improved nutrition for women and children Source: REACH Secretariat Action spans beyond 2015 as hunger remains a problem, and nutrition issues gain a stronger emphasis in the post-2015 agenda

Where do we begin?

REACH applies a Theory of Change to accelerate progress towards MDG1, target 3 If we address these issues with these strategies to improve governance then we can achieve this impact Little consensus on the causal problems of undernutrition Limited political commitment Weak coordination of gov'ts with UN agencies and other stakeholders Nutrition is not seen as a multi-sectoral issue Poor capacity development Accountability and responsibility is undervalued REACH outcomes 1. Increased awareness and consensus of stakeholders 2. Strengthened national policies and programmes 3. Increased human and institutional capacity 4. Increased effectiveness and accountability Political support to fund programs and coordinated nutrition efforts Nutritional impact and coverage Improved nutrition for women and children Source: REACH Secretariat Action spans beyond 2015 as hunger remains a problem, and nutrition issues gain a stronger emphasis in the post-2015 agenda

DRAFT Identify the scope and magnitude of nutrition problems, illustrating how they have changed over time (Ethiopia) Underweight children <5 Stunted children <5 % 50 40 30 20 42.8% 42.8% 34.4% 28.7% WHO threshold 30% 23.8% MDG target % 60 40 20 0 67% 56.8% 1992* Other NS 2000* DHS 52.2% 2005* DHS Wasted children <5 44.4% 2011 DHS WHO threshold 40% 10 0 1992* Other NS 2000* DHS 2005* DHS 2011 DHS % 15 10 5 12.3% 12.3% 9.7% WHO threshold 15% 0 N/a 1992* Other NS 2000* DHS 2005* DHS 2011 DHS *Note: Prevalence recalculated using 2006 WHO growth standards Source: DHS (2011); DHS (2005); DHS (2000); Other NS (1992); WHO Conversion tool from NCHS reference into estimates based on the WHO Child Growth Standards

Compare prevalence with absolute numbers, by region, to inform planning and prioritisation exercises (Nepal) Stunting among children <5 years old, 2011 Far-western Prevalence of stunting >40% 30-39.9% 20-29.9% Mid-western Western Central Eastern Highest # s 162,018 235,926 232,564 425,250 261,262 46% 50% 37% 38% 37% Highest % Source: Census 2011 population projection, Estimated Target Population (2011-12), DoHS, Kathmandu, NDHS 2011

Highlight the nuances: While largest numbers of stunted children in North, stunting is on the rise in Southern & Eastern regions (Sierra Leone) Largest absolute numbers of malnourished children in Northern region But stunting has decreased in North, while increasing in Southern and Eastern regions Stunting prevalence of children 6-59 months, 2010 Highest Change in stunting prevalence, 2008-2010 Decrease Increase -5+% 0 +15+% Lowest 34.5% 109,000 children Kambia Bombali Koinadugu 22% 44,000 children 39% 89,000 children 39.6% 85,000 children West Urban West Rural Port Loko Moyamba Tonkolili Bo Kenema Kono Kailahun Bonthe Pujehun Note: SMART 2010 prevalence data provided for children 6-59 months. Absolute numbers for children 0-59 months using SMART 2010 prevalence rates for children 6-59 months. Source: DHS, 2009; SMART Survey, 2010; REACH analysis.

Summarise the nutrition situation from A to Z (Iringa Region, Tanzania) Not currently a serious problem Requiring action Serious problem requiring urgent action Not applicable DRAFT

Underscore any marked disparities e.g. rural/urban divide, gender (Mozambique) Indicator URBAN Severity Trend RURAL Severity Trend Stunting Prevalence of stunting among children 6-59 mo. old 35.0 % 45.5% Nutritional Impact Wasting GAM prevalence among children 6-59 mo. old 3.8 % 6.7% SAM prevalence among children 6-59 mo. old 1.4% 2.4% Vitamin A deficiency Children <5 with Vitamin A deficiency 63.3 % n.a. 73.1% n.a. Iron deficiency Children 6-59 mo. old with anemia 59.7 % n.a. 72.0 % n.a. Women 15-49 yrs.old with anemia 51.8 % n.a. 55.1 % n.a. IDD Median urinary iodine level for school-aged children 89.6 µg/l n.a. 59.2 µg/l n.a. Food Security Households with poor or borderline food consumption - - - - - - - - - - - - Global Hunger Index Score - - - - - - - - - - - - Underlying Causes Health and Sanitation Under 5 mortality rate 100 111 Proportion of institutional deliveries 81.8 % 44.5%. Households with access to improved water sources 85.3 % n.a. 37.1 % n.a. Households with access to improved sanitation facilities 43.7 % TBD n.a. 12.3 % TBD n.a. Care Timely initiation of breastfeeding 75.0 % 12.3 % Infants 0-5 mo. old exclusively breastfed - - - - - - - - - - - - Children 6-23 mo. old receiving an acceptable diet 12.3 % n.a. 13.3% n.a. Households with a washing station equipped with water and soap/cleansing material 48.6 % n.a. 24.3% n.a. Households taking 30+ minutes to fetch water 18.1 % 48.6 % Education Females that completed primary school or higher 49.0% 11.2% Females 15-49 yrs. who are literate 67.8 % 25.5 % Basic Causes Population Total fertility rate 4.5 6.6 Gender Women who were married before 18 yrs. 42.4 % n.a. 56.4 % n.a. Women ages 15-19 who already had a child or are currently pregnant 30.8 %. 41.5 % Poverty Population living under national poverty line 49.6 % 56.9 % - - SEVERITY GINI Index - - - - - - - - - - - - Not currently a serious problem Requiring action Urgent Problem requiring urgent action Not applicable TRENDS Improving Deteriorating No Change

What can be done? What does multi-sectoral action really mean?

REACH applies a Theory of Change to accelerate progress towards MDG1, target 2 If we address these issues with these strategies to improve governance then we can achieve this impact Little consensus on the causal problems of undernutrition Limited political commitment Weak coordination of gov'ts with UN agencies and other stakeholders Nutrition is not seen as a multi-sectoral issue Poor capacity development Accountability and responsibility is undervalued REACH outcomes 1. Increased awareness and consensus of stakeholders 2. Strengthened national policies and programmes 3. Increased human and institutional capacity 4. Increased effectiveness and accountability Political support to fund programs and coordinated nutrition efforts Nutritional impact and coverage Improved nutrition for women and children Source: REACH Secretariat Action spans beyond 2015 as hunger remains a problem, and nutrition issues gain a stronger emphasis in the post-2015 agenda

Making practical nutrition knowledge across the multi-sectoral landscape more accessible and coherent Audience Primary audience: REACH facilitators Secondary audience: Others, particularly non-technical practitioners Purpose To help breakdown what multi-sectoral nutrition action means into concrete terms To highlight the types of nutrition-related interventions carried out within the respective sectors and any cross-cutting issues To identify the linkages between sectorspecific action and opportunities for integrated action in a logical and synthesised manner

Developing Action Sheets on nutrition-related actions for thematic areas, including nutrition-sensitive, that transcend institutional mandates Food, agriculture & diets Food Consumption 2 Improvement of local recipes Public guidance & consumer awareness/protection Horticulture/Crops Diversification & locally adapted varieties Biofortification Livestock & Fisheries/Aquaculture Small-scale animal husbandry Animal health services Food Processing & Storage Fortification Food preservation (incl. complementary foods) Food storage Social protection In-kind Transfers General food distribution Blanket Supplementary Feeding Food-for-assets/training School feeding Potential actions 1 Maternal & child care Infant & Young Child Feeding Breastfeeding promotion & support Complementary feeding & support Infant feeding in context of HIV Hygiene Personal hygiene promotion Food hygiene & preparation What d Care for Children/ P&L Women Childcare support/caregiver workload Care to pregnant/lactating women Health Behaviours Health-seeking behaviour Insecticide-treated nets (anti-malaria) Household water treatment Family planning behaviour Cash & Vouchers Cash/Vouchers-forwork/training/education Conditional cash transfers Capacity development * Nutrition education & social marketing 1. Each country s NNP is specific to the country s situation and therefore a selection of tailored actions is pursued 2. Action Sheets being developed for the thematic areas marked in bold, italic text under the four respective categories Source: REACH Secretariat Health-based Treatment of Acute Malnutrition Treatment of SAM Treatment of MAM Disease Prevention & Management Deworming ORT Vaccinations (polio, measles, etc.) IPTp (anti-malaria) HIV treatment & PMTCT DOTs for TB & antibiotics for pneumonia Micronutrient Supplementation Iron+folic acid/iron supplementation Vitamin A/D/E/zinc/Ca supplementation Multiple micronutrient supplements (powders & capsules) Water & Sanitation Construction of safe water points Latrine construction Other Social Protection Public works Maternity/paternity protection Subsidies/taxes Context assessment Do no harm Equity Women s empowerment Multi-sectoral collaboration M&E (explicit nutrition outcomes & indicators)

How are we doing?

Critical to understand who is doing what where for the selected actions and compare to the need e.g. stunting levels (Rwanda)

Care Once actions are selected and implemented, information systems/ tools needed to track progress (Mozambique) Key Problems Poor IYCF Practices Inadequate maternal care Health and Sanitation Soil, water Healthcare borne Food Micronutrient Deficiencies endemic diseases Insufficient macro and micronutrient intake Food Insecurity Intervention areas Status Indicator Status Year Coverage Indicator Coverage Year Exclusive breastfeeding Complementary Feeding Family Planning % of children (0-5 months) exclusively breastfed % of women who started timely initiation of breastfeeding 42.8 76.7 2011 % of pregnant/lactating women receiving promotion on 2011 exclusive breast feeding % of children 6-23 mowho fed according to IYCF practices 13.0 2011 % of mothers receiving education on complementary feeding % adolescents girls 15-19 using contraceptives 8.4 2011 % of adolescent girls 15-19 counseled on the use of contraceptives Median month interval between births between births 34.8 2011 % of women 15-49 using contraceptives and declared among women 15-49 yrs they want to wait 2 or more years to have their next child % of households with a hand washing station equipped with water and soap/cleansing material % of children being treated with ORS and Zinc - - - - - 6.6 2011 31.7 2011 Hygiene promotion % of children 6-59 mo with diarrhea 11.1 2011 - - Distribution of nutrition supplement % of pregnant women 15-49 yrs who are underweight - -. % of pregnant women receiving food supplements - - Latrines % of children whose feces were securely eliminated 77.8 2011 % of HH with improved sanitation 21.7 2011 Deworming % of children 12-59 mo with parasites detected in stools - - % children 12-59 months who were dewormed in the past 6 months 46.3* 2011 % of women receiving IPT during pregnancy in ANC 18.6 2011 ANC % of pregnant women attending 4+ ANC visits 50.6 2011 % of pregnant women 15-49 yrswho during ANC 42.3 2011 Median month of pregnancy for first ANC visit 5.4 2011 received counseling, were tested and received the results for HIV Vitamin A % of children 6-59 months receiving VAS in the past 6 % of children with Vitamin A deficiency 68.8 2002 Supplementation months 71.5 2011 Iron/folate % of women who consumed iron/folatesupplements for % of pregnant women with anemia 50.9 2011 Supplementation 90+ days during pregnancy 25.9 2011 Distribution of MNPs % of children 6-59 mo with anemia 68.7 2011 % of children 6-59 mo receiving MNPs - - Iodized salt Median urinary iodine level (µg/l) among school aged children 6-12 yrs 60.3 2004 % households consuming iodized salt 44.8 2011 Food Fortification Nutrition Education Production of nutritious foods Appropriate processing and storage Cash transfers/subsidies % of processing industries that fortified selected foods and comply with the regulation and standards developed - -. % of fortified products in the market (wheat four and oil) - - % of children 6-23 moconsuming vitamin A rich foods % of households with poor or borderline food consumption 27.4. 2010 % of children consuming iron rich foods % of households consuming Iron rich foods - - % of households producing iron rich foods % of households consuming vitamin A rich foods -. - % of households producing vitamin A rich foods % of households with chronic food insecurity % of producers that had crop losses** 34.0 68.8 2009 2012 % of households storing their harvest in traditional/improved barn 71.0 45.2 - - 2011 2011 - - 56.0 2009 % of income spent on food 51.4 2008 % of households that benefited from income transfer - -

Village in Moyamba district, Sierra Leone How does Fatou s household access/benefit from nutrition actions? Drying Floor Church School Market Centre PHU R O A D Vocational Centre Police Post Town Crier Mosque Well Community Bank Committees at village level committees at Chiefdom or ward level

Thank you