unicef esaro nutrition newsletter 2014
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NEWSLETTER
Back to the Triple-A Approach By Bjorn Ljungqvist
The 1990 UNICEF Nutrition Strategy consists of two equally important components: the Conceptual Framework of Causality and the Triple-A approach. The Conceptual Framework is the basis for a multisectoral, multi-stakeholder approach to nutrition, with food, health and care being components that are all necessary, though not one by itself sufficient. However, this part is well established and understood. The second part, the Triple-A approach, seems to have been neglected, but is now coming back as a critical component of the nutrition scaling-up process.
African Regional Nutrition Strategy
Assessment - Analysis - Action
Africa’s Nutrition Security Partnership
Monitoring Implementation and Demonstrating Results Workshop
A Framework of Multisectoral Nutrition Systems
While the conceptual framework guides the discernment of which
information needs monitoring, the Triple-A approach (of
Assessment, Analysis and Action in a consecutive, iterative and
continual cycle) guides how this information should be used. The
cycle may start with a household-level assessment, with the
mother gauging the growth of her child, or with an assessment at
the community, district or national level of the nutrition situation
of the population. The assessment depends on the awareness of
the problem and the commitment to act. It is thus partly also
dependent on the information available and the systems that
allow this information to be understood and used. After an initial
assessment, the causative factors and determinants need to be
analysed. The analysis is improved when there are inputs from
people who are close to the situation and understand the context
well, i.e., people at the community level as well as those who are
experienced and trained to do such analyses. Actions are taken
based on the assessments and analyses. However, contexts change
and the actions themselves may lead to new situations requiring
the need to re-assess, reanalyse and re-think the actions. Strong
motivation, supported by advocacy and social mobilization, is
needed to keep the cycle going.
Rather than relying on the will of a leader or authority, the Triple-A
Approach should be anchored on human rights. This anchor
automatically identifies the duty bearers as managers and the
claim holders as the centre of their own development. The Triple-A
Approach should be done at multiple levels and should involve and
empower the communities to contribute to their own nutrition
improvement.
African Union Nutrition Champion
SUN Movement Global 2014 Gathering
Global Attention on Nutrition—ICN2
Ethiopia and Uganda Multisectoral Nutrition Policies and Programmes
Regional Consultation Emergency Food Security and Nutrition Preparedness and Response in the Horn of Africa
From the Regional Director
2
For this to work, however, there is a critical
need for capacity. Assessment, analysis and
actions all require capacity by local actors,
and we have to be aware that for monitoring
systems to work, they have to be based on
strengthening of local capacities and not
remain a matter of refined procedures at
national and international levels.
Communities and societies are complex
systems that are not fully predictable, but
explainable at points in time. In the face of
changing situations and contexts, it is
important to monitor as closely as possible
using key indicators and iterative planning,
so that revisions and adaptations of plans
throughout succeeding implementation
cycles and learning loops are built into the
system. Monitoring should continuously
provide real-time data for immediate and
ongoing decision-making from key decision
makers, thereby enabling a Triple-A
approach to monitoring, learning and
adaptation.
The knowledge from the past two decades in
nutrition has taken us from implementing
relatively simple solutions and nutrition-
specific interventions to a re-emphasis of the
multisectoral approach to nutrition
programmes. We can reduce stunting by
approximately 20% with nutrition-specific
interventions, but we need to also influence
the other 80%. That can be achieved through
nutrition-sensitive approaches and an
enabling environment together with other
sectors such as agriculture, social protection,
and education.
Bjorn Ljungqvist is an independent consultant who
was instrumental in defining the Strategy for
Improved Nutrition of Children and Women in
Developing Countries as a UNICEF policy in 1990.
Four years since the start of the Scaling Up
Nutrition (SUN) Movement, much progress
has been achieved globally. There are now
54 SUN countries, 17 of them from Eastern
and Southern Africa. Political attention to
nutrition has increased; multi-stakeholder
platforms are in place in most of the SUN
countries and aligning support to
governments; financial commitments for
nutrition have increased; and many countries
are intensifying their efforts to scale up high-
impact, evidence-based nutrition
interventions. In Eastern and Southern
Africa, however, stunting in under-five
children continues to be a significant
bottleneck for children to realize their full
potential. An estimated 28 million or close to
39% of children under-five are stunted (ranging from 29% in Namibia and Angola to
58% in Burundi). The stunting prevalence has changed very little over the past 20
years.
It is with this in mind, that the Eastern and Southern Africa Regional Management
Team has endorsed stunting reduction as one of the programmatic priorities for our
region in the period 2014-2017. The strategies that will be key for reducing stunting
include policy advocacy; national, regional and continental partnerships; scaling up
of proven interventions; capacity development; communication for behaviour and
social change; evidence generation and knowledge sharing; and South-South
cooperation. These strategies will be applied to programmatic focus areas of infant
and young child feeding; addressing micronutrient deficiencies; management of
severe acute malnutrition; and sanitation and hygiene. Ensuring programmes across
the region produce the greatest impact, achieve the best possible results and make
optimal use of resources entails regular performance monitoring.
I hope that you find this edition of the Newsletter useful and informative, as we
continue our collective actions to help deliver results for children in Eastern and
Southern Africa.
Leila Pakkala
Regional Director
Eastern and Southern Africa
UNICEF Eastern and Southern Africa
Regional Management Team has
endorsed stunting reduction as one of
the programmatic priorities for our
region in the period 2014-2017.
From the Regional Director
Triple-A
Approach
3
The African Regional Nutrition Strategy (ARNS) 2005-2015 was
adopted in 2005 as Africa’s contribution to the achievement of the
Millennium Development Goals. The task of revising the ARNS was
assigned to UNICEF during the 5th Meeting of the African Task
Force for Food and Nutrition Development (ATFFND), which was
held in Maseru, 29-30 July 2013.
During the 6th ATFFND Meeting in Nairobi, 14-15 May 2014,
UNICEF consultant Bjorn Ljungqvist presented the progress made
in revising the ARNS, based on consultations with Regional
Economic and Health Communities, UN agencies, development
partners and other stakeholders.
Whereas ARNS 2005-2015 focused on development frameworks
and nutrition programme operational strategies, the revised ARNS
2015-2025 represents a paradigm shift towards positioning the
African Union Commission (AUC) as an implementing institution,
and promoting execution of existing frameworks rather than
developing new ones. It is consistent with the AUC’s vision and
mission statement and is aligned with the AUC Strategic Plan 2014-
2017 as it applies to nutrition issues in Africa.
ARNS 2015-2025 articulates the following roles for the AUC: 1)
defines standards, norms, policies and frameworks for AU Member
State adoption and ratification; 2) convenes and facilitates
consensus on issues related to nutrition security; 3) advocates and
promotes implementation; and 4) establishes an architecture for
decision-making. These actions would then lead to the desired
outcomes of having AU Member States adopt, ratify and
domesticate norms; creating an enabling environment; providing
essential services; and establishing good nutrition governance.
These outputs and outcomes would then lead to the overall ARNS
impact objective of contributing to the global World Health
Assembly 2011 targets for nutrition that are to be achieved by
2025.
The participants of the meeting upheld ARNS 2015-2025 as a high-
level strategic document that is in line with the strategic vision of
the AUC for an integrated, prosperous and peaceful Africa that is
driven by its own citizens, and represents a dynamic force in the
global arena.
ARNS is now being taken forward for final validation by the AUC.
Recently appointed African Nutrition Champion, His Majesty King
Letsie III of the Kingdom of Lesotho pressed African governments
to commit resources to their nutrition plans to allow them to reap
the benefits of investment in nutrition. The King made the call
during a breakfast meeting held on the sidelines of the 23rd
African Union Heads of State
and Government Summit
under the theme,
“Strengthening Advocacy for
Improved Nutrition and
Inclusive Development”, in
June 2014, Malabo,
Equatorial Guinea.
“Investing in nutrition is an
investment in the social and
economic development of the
continent,” said the King,
emphasizing that “poor
nutrition is closely linked to
extreme poverty, and improving nutrition is a prerequisite for
reaching the targets of the Millennium Development Goals,
especially those related to education and health”.
“This places a heavy burden on us to work hard, in collaboration
with stakeholders outside nutrition, in order to see positive results
on economies of African countries,” added His Majesty.
“Investing in nutrition will greatly improve productivity, economic
growth, and will promote education, intellectual capacity and the
social development of people,” said Dr. Mustapha Sidiki Kaloko,
Commissioner for Social Affairs of the African Union Commission.
“The nutritional status of a child is influenced by three broad
factors: intake of quality food, health and care,” said Dr. Noel
Marie Zagre, Regional Nutrition Advisor for UNICEF Eastern and
Southern Africa. “The programmes that address malnutrition
therefore have to be multisectoral and multi-stakeholder.”
Revision of African
Regional Nutrition
Strategy
African Union
Nutrition Champion
urges African Leaders
to Invest in Nutrition
4
During this AU Summit, the Heads of State and Government of
the African Union went on to make a Declaration on Nutrition
Security for Inclusive Economic Growth and Sustainable
Development in Africa. In this Declaration, governments made a
commitment to end child stunting, in particular, focusing on the
first 1000 Days as the only window of opportunity during which
permanent and irreversible physical and mental damage would
be avoided; position this goal as a high-level objective in national
development plans and strategies; and establish long-term
targets that give all children equal chance for success, by
eliminating the additional barriers imposed by child under-
nutrition.
In October, during the celebration of the 5th Africa Day for Food
and Nutrition Security (ADFNS) held in Kinshasa, Democratic
Republic of Congo, the King recalled the Malabo Declaration on
Nutrition Security and urged the countries to commit to concrete
actions including demonstrating leadership in ensuring the
development of a common results framework for each Member
State; institutionalizing a monitoring dashboard; setting up of a
parliamentarian committee to engage on nutrition issues;
establishing a separate budget line specific to nutrition
interventions; and organizing a sustainable network of
community workers to deliver nutrition services.
The King reminded the participants that the annual celebration of
the ADFNS serves as a timely reminder of governments’
responsibilities toward infants and young children as set out in
Article 14 of the African Charter on the Rights and Welfare of the
Child and Article 24 of the Convention on the Rights of the Child
that recognize the right of the child to the enjoyment of the
highest attainable standard of health.
Fifty-four countries, home to half the world’s malnourished
children, have joined the Scaling Up Nutrition (SUN) Movement.
The annual Global Gatherings for the movement provides an
opportunity for SUN countries and networks to share progress,
learn from each other and be inspired to achieve even more. This
year, the Global Gathering was held in Rome in advance of the
Second International Conference on Nutrition (ICN2). The 300
delegates from the SUN Movement countries, networks and the
Lead Group participated in the gathering.
Plenary and parallel sessions included discussions on the four
Communities of Practice (COP). UNICEF ESARO’s contribution was
acknowledged particularly for COP 1 - Planning, Costing,
Implementing and Financing Multisectoral Actions for Improved
Nutrition during the November 2013 Workshop on Costing and
Tracking Investments in Support of Scaling Up Nutrition; and COP
3 - Reliable Monitoring of Progress, Evaluation of Outcomes and
Demonstration of Nutrition Results during the May 2014
Workshop on Monitoring Implementation and Demonstration
Results. These meetings have become the key milestones to kick-
start discussions on how national, regional and global partners
can respond and build capacities.
The Second International Conference on Nutrition (ICN2) was held in Rome, Italy, 19-21 November 2014. ICN2 was a high-level intergovernmental meeting, focusing on galvanizing global attention to tackle malnutrition over the coming decades with a view to achieving the global nutrition targets agreed upon at the World Health Assembly by 2025. ICN2 was jointly organized by FAO and WHO, in cooperation with IFAD, IFPRI, UNESCO, World Bank, WTO, WFP, the High Level Task Force on the Global Food Security Crisis (HLTF) and UNICEF. Over 2,200 participants attended the meeting, including representatives from more than 170 governments, 150 from civil society organizations and nearly 100 from the private sector.
During the conference, the Rome Declaration on Nutrition and the Framework for Action were endorsed by the participating Heads of State and Government, committing world leaders to redouble political commitment and social participation to improve nutrition; align policies that impact nutrition across different ministries; increase responsible and sustainable investment in nutrition; and establish national policies aimed at eradicating malnutrition and transforming food systems to make nutritious diets available to all.
SUN Movement
Global 2014
Gathering
Global Attention on
Nutrition—ICN2
5
Results-Based Management (RBM) is a management
approach focused on defining, measuring, and achieving results
(see illustration for definition and phases of RBM). Monitoring is
measuring and tracking what is happening to the programme and
the context. Monitoring (both performance monitoring and
situation monitoring) thus provides accountability for
implementation, improves programme implementation, and
triggers rapid adaptation of programme response (particularly in
crises or unstable contexts). The “dashboard” is a tool for
performance monitoring and management that can provide a
visual representation of performance measures, ensure total
visibility of key performance indicators, save time compared to
generating multiple reports, readily identify and correct negative
trends in performance indicators, and enable informed decisions
based on real-time data.
The workshop allowed participants to understand the concept of results-based monitoring and get practical guidance on data collection; analysis and performance measurement; feedback and use of information; and building systems that contribute towards a country “dashboard” for tracking implementation rates. Members of the SUN Movement Networks presented options for partners to support countries through Communities of Practice (COPs) during a panel discussion.
The country teams attending the Workshop identified steps needed to improve their information and monitoring systems and for what external expertise might be required. These two sets of needs fell under three broad working areas: 1) development, agreement and use of a common results framework for nutrition; 2) systems strengthening for quality data collection and
management; and 3) capacity building for cross-sectoral analysis, interpretation and use of data. These needs were further discussed during the panel discussion wherein representatives from the Maximising the Quality of Scaling Up Nutrition (MQSUN) Consortium, Global SUN Business Network, SUN Global Civil Society Network, SUN UN Systems Network and the SUN Donor Network affirmed their support to countries on monitoring and evaluation.
In closing, participants were reminded to consider changing situations and contexts in nutrition programming and the importance of close monitoring of key indicators and use of iterative planning so that revisions and adaptations of plans throughout the implementation are built into the system.
Monitoring Implementation and
Demonstrating Results Workshop The Workshop, organized by UNICEF on behalf of the UN Scaling Up Nutrition (SUN) Network was held in Nairobi, 12-13 May
2014. The aim was to strengthen country capacity for results-oriented monitoring of nutrition programmes towards improved
performance, accountability and learning. There were 72 participants, 43 from 14 countries in Eastern and Southern Africa and
29 regional and global partners and resource persons.
6
Evidence-based programmes usually include a strong theoretical
foundation for specific target populations (i.e., articulating a
theory of change and specifying the rights holders), identification
of active agents of change (duty bearers), specification of
necessary activities and organizational support (investments),
quality data collection and procedures (monitoring), and evidence
of effectiveness (evaluation). The framework for programming
excellence includes accountability for resources and results with
feedback loops and action between the activities of strengthening
the situation analysis, improving programme design and execution,
and stronger measurement and reporting. The framework for
programming excellence includes accountability for resources and
results with feedback loops and action between the activities of
strengthening the situation analysis, improving programme design
and execution, and stronger measurement and reporting.
Monitoring should continuously provide real-time data for
immediate and on-going decision-making from key decision
makers; thereby applying the Triple-A Approach (Assess, Analyse
and Act) to monitoring, learning and adaptation. For this to work,
however, there is a critical need for capacity by local actors and an
understanding that monitoring systems are based on
strengthening local capacities rather than refining procedures at
national and international levels.
EU-UNICEF
Africa’s
Nutrition
Security
Partnership
To fight the widespread and growing problem of undernutrition,
the EU and UNICEF have been working in partnership on the
Africa’s Nutrition Security Partnership (ANSP) to improve nutrition
security among women and young children in the continent.
ANSP is a four-year programme (2011-2015) that integrates and
positions nutrition security within the African development
agenda and focuses on improving nutrition security among
women and young children in Africa. The Partnership provides
technical advice as well as actual programme implementation
support including capacity building and systems development in
the four countries.
The Annual Review of the implementation held in Addis Ababa,
14-15 October 2014, aimed to assess achievements, challenges,
and lessons learned during the third year of implementation, as
well as to discuss improvements in the implementation for the last
year of the ANSP. The Meeting also presented the ANSP Global
Logframe which was revised based on recommendations from the
last ANSP Annual Review Meeting held in Entebbe, Uganda, 8-10
April 2014.
Progress in ANSP implementation in the last three years in the
four key result areas include:
Result Area 1: Up-stream policy development and nutrition
security awareness: The increased awareness on nutrition security
has resulted in an improved and enabling political environment
where continental, regional and national policies are aligned
towards improving the nutrition situation of women and children
by integrating nutrition across multiple sectors. The draft African
Regional Nutrition Strategy (ARNS) and sub-regional nutrition
frameworks and strategies emphasize leadership, accountability
and multisectoral coordination in order to achieve results. The
four focus countries - Burkina Faso, Ethiopia, Mali and Uganda -
have developed national nutrition plans and policies that highlight
the multisectoral nature of undernutrition and the solutions
therein.
Result Area 2: Institutional development and capacity building:
Strong strategic, managerial and technical capacities are being
developed in countries based on extensive gap assessments on
human resource need for nutrition. Technical training modules are
being developed for Eastern and Southern and West and Central
African countries that will be applicable to pre- and in-service
nutrition training as well as for nutrition-sensitive sectors. Work
being led by Cornell University is breaking new ground in defining,
understanding and documenting how multisectoral nutrition
systems are built in the face of changing contexts and the need for
adaptability.
7
Result Area 3: Data analysis and knowledge sharing: National
information systems such as the Annual Nutritional Surveys using
Standardized Monitoring and Assessment of Relief and
Transitions tools (SMART Surveys) in Burkina Faso and Mali, the
Integrated Supportive Supervision and Monitoring System in
Ethiopia, and the Annual Food Security and Nutrition Assessment
in Uganda are being implemented with relevant information
available at all levels for decision-making. At regional and
continental levels, the completion of the technical work behind
the NutritionInfo web-based database will allow ANSP to come
back to discussions with the AUC on how best this standardized
nutrition information database can support monitoring systems
at the continental level.
Result Area 4: Scaling up interventions: Multisectoral nutrition
programmes are being implemented at the community level in
ANSP focus areas where multisectoral coordination structures
are in place to ensure that communities, families, mothers and
children have access to quality nutrition-specific and nutrition-
sensitive interventions. Information from monitoring systems in
these countries are already showing improvements in coverage
rates, behaviours and nutritional status. ANSP will continue to
adjust programmes in order to address identified bottlenecks in
specific areas.
The communication initiatives in the first three years of the ANSP
have provided good visibility for the joint partnership between
the EU and UNICEF. Moreover, they have helped increase the
political commitment and strengthen dialogue on nutrition
security among key counterparts. To date, a significant amount
of work has been completed to raise awareness about the ANSP,
and the support of the European Union. UNICEF has promoted
the EU-UNICEF ANSP Partnership via a web portal featuring
multimedia packages, video and still photography, and has
actively engaged partners.
Presentations from each of the country delegations highlighted
community-based scaling up of nutrition interventions being
implemented in the country. Each country explained the context
in the ANSP focus areas; the multisectoral interventions being
implemented; the management and governance structures at the
community, regional and national levels and how they interact;
how monitoring and evaluation information feeds into the
governance and adjustment of the programme; some key results
achieved; the sustainability of the programme; and, lessons
learned and challenges. This horizontal learning enabled the
countries to discuss details of success factors in the ANSP focus
areas.
Overall, the project components are progressing as planned. In
the last year of implementation, the ANSP focus countries will
continue supporting the implementation of community-based
nutrition programmes, reinforcing multisectoral collaboration at
district and national levels, and strengthening systems
development to increase coverage of nutrition-specific
interventions and nutrition-sensitive development in order to
consolidate achievements from the past three years. An external
Endline Evaluation will be executed by ETC Nederland BV before
the end of Year 4 of ANSP implementation. The Annual Review
Meeting concluded with a commitment from all stakeholders to
continue to critically appraise progress and work towards
identified results.
The Four Pillars of the Partnership:
1. Up-Stream Policy Development & Nutrition
Security Awareness. National policies are aligned
to impact nutrition by integrating nutrition as a
key objective across different sectors.
2. Institutional Development and Capacity Building.
National nutrition programmes are strategic and
have the capacity to adapt to changing contexts
that influence nutrition programming in the
country.
3. Data Analysis & Knowledge Sharing. Strong
national oversight for nutrition with relevant and
sustainable nutrition information systems
available at all levels for decision-making.
4. Scaling Up Interventions. Communities, families,
mothers and children in focus areas have access
to quality nutrition-specific and nutrition-
sensitive interventions.
8
Eastern and Southern
Africa Regional
Priorities
Within the framework of the UNICEF Strategic Plan 2014-2017,
the UNICEF Regional Management Team identified five
programmatic priorities to focus cross-country action, learning
and reinforce joint accountability:
Enabling children to survive and thrive.
Reducing stunting to provide opportunities for children to
realize their full potential.
Improving education quality and learning outcomes to
prepare children for the future.
Achieving results for adolescents (R4A) that help them
manage risks and realize their full potential.
Scaling up social protection interventions to reduce child
poverty and other vulnerabilities that impede the full
realization of child rights.
These regional priorities will provide the basis to focus investment
and resources on selected critical actions and interventions that
have the highest potential for scaling up and delivery of equitable
results for children. The regional priorities reinforce, rather than
replace, the country-specific priorities outlined in country
programme documents and agreed with national counterparts,
and articulate what the UNICEF Eastern and Southern Africa team
will contribute as a region to the achievement of organization-
wide Strategic Plan results.
David Pelletier, Associate Professor of Nutrition Policy in the
Division of Nutritional Science and Suzanne Gervais, Sr. Extension
Associate, both at Cornell University, are the Principal
Investigators for the work on Strategic Capacity and Adaptive
Management of Multisectoral Nutrition Policies and Programmes
in cooperation with UNICEF.
The African’s Nutrition Security Partnership (ANSP) is an EU-
UNICEF collaboration that seeks to reduce stunting in four focus
countries—Burkina Faso, Ethiopia, Mali and Uganda—by
strengthening the enabling policy environment for multisectoral
approaches and operationalizing multisectoral policies and plans
in selected regions or districts in these countries. Cornell
University has been engaged to support ANSP stakeholder efforts
in these four countries and to document the lessons emerging
Building Strategic
Capacities
from the development and operationalization of multisectoral nutrition at national and sub-national levels for dissemination within and beyond these countries. Below is an excerpt from an interim brief written at an early stage of Cornell’s engagement with the ANSP countries. The full brief can be obtained from David Pelletier: dlp5@cornell.edu.
A Framework for the Multisectoral Nutrition
System
Although there is now an abundant supply of agency guidance
documents on multisectoral nutrition and a growing number of
national multisectoral nutrition plans, there does not yet appear
to be a clear or shared understanding of how to operationalize
this approach at country level. This is the case in the four ANSP
countries, where a common remark is “this is all new and we are
learning as we go,” and stakeholders with broader regional
responsibilities indicate that it is also true in other countries on
the continent. It is in this context that the ANSP stakeholders
appreciated a visual representation of a multisectoral nutrition
system that the Cornell team created based on the early
observations in the ANSP countries and previous experience. This
representation uses a land cruiser as a metaphor. The nutrition
system, like this metaphor, includes seven interacting elements,
all of which are required for sustainable and effective
functioning: a clear purpose, components and connections,
alignment, fuel, designers and engineers, servicing and repairs
and resources.
Early observations from the ANSP countries indicates that a great
deal of attention is given to the creation of coordination
structures for implementing multisectoral nutrition system
policies and plans, and there is a clear recognition that a great
deal of work is needed to make these structures functional. What
has been lacking, however, is a clear sense of the priority
activities needed to make them functional. When all the
elements of the land cruiser metaphor are integrated (see
illustration), it provides a simple visual reminder of some of these
crucial issues and the sequence for tackling them.
While this system illustration does signal what issues need
attention when building or operationalizing a multisectoral
nutrition system it does not by itself provide a clear sense of how
to address these various issues. For instance, while “alignment”
among government and non-government actors is important, the
illustration does not indicate how this can be achieved in
practice. Similarly, “consistent incentives” is noted but the
illustration does not indicate how to create these in various
contexts. A prominent example of the latter is when there may
be real or perceived competition or conflict between nutrition
goals and the long-standing goals and incentives in a ministry.
Answering the “How” question on these issues, in very concrete
and practical ways, is an important part of the Cornell’s learning
agenda in the ANSP countries, as in all the SUN countries.
9
This system lens reveals the magnitude of the challenge in
operationalizing a multisectoral nutrition system. When applied to
the ANSP countries this lens reveals some important variations in
the design of the multisectoral nutrition structures and a small
core of dedicated individuals advancing the work who have taken
on multisectoral duties in addition to their usual duties. Success is
likely to require an expanded core team at the national level, an
appropriate time horizon and a realistic set of political
expectations in order to provide the space for high quality work.
The system lens also reveals a need to address an “alignment gap”
at country level and a “dissemination gap” from global to country
level, both of which need attention in the early stages of the
multisectoral nutrition system effort.
Finally, the application of a systems lens highlights the
extraordinary importance and downstream consequences of the
seemingly routine “busy work” involved with building a
multisectoral nutrition system. This last observation suggests a
need for greater attention, support and recognition for seemingly
routine activities in order to ensure the highest possible quality
and to enable the updating of the design and implementation of
multisectoral nutrition system policies and interventions based on
experience. Additionally, strategic capacities and adaptive
management must be strengthened to facilitate stronger
alignment and continued progress on the multisectoral agenda at
national and sub-national levels.
10
Focus on Ethiopia and Uganda: Strategic
capacity and adaptive management of
multisectoral nutrition policies
FAO, UNHCR, UNICEF AND WFP Regional
Consultation—Emergency Food Security and
Nutrition Preparedness and Response in the
Horn of Africa
Background On 25–26 September 2014, representatives of FAO, UNHCR, UNICEF and WFP country teams from Djibouti, Eritrea, Ethiopia, Kenya, Somalia, Sudan and Uganda and the respective regional offices and OCHA met in Nairobi, Kenya, to discuss the current situation and joint approaches towards food security, nutrition and refugees situation in the Horn of Africa. The first day of the meeting started with an overview of the region, followed by rich discussion and exchange of ideas among the participants. The results of the regional consultation were then shared with the donor community and peer organizations on the second day of the meeting. Regional nutrition and food security overview The current situation is not an acute regional food and nutrition crisis
(as in 2011) and yet the situation is urgent, with all eight countries (including South Sudan) in a state of chronic crisis with pockets of acute food insecurity and emergency-level malnutrition. Deeply embedded vulnerability, with chronic, long-term food insecure and malnourished populations continues to be the dominant factor. Across the region, more than 12 million people are in emergency or crisis food security situations. Key recommended actions At country level:
To finalize preparedness and response country action plans for food security and nutrition programming, that combines humanitarian (short term) and development (medium and long term) actions and promotes resilience by addressing the long-term drivers of vulnerability.
Enhanced inter-agency collaboration and accountability for joint commitments.
Both Ethiopia and Uganda have made great strides in the first year
of implementation of the partnership between UNICEF and Cornell
University in advancing the development of their multisectoral
nutrition approach and in establishing proper structures for the
implementation of the National Nutrition Policy (NNP) in Ethiopia
and of the Uganda Nutrition Action Plan (UNAP) in Uganda.
In Ethiopia, the partnership has played a technical facilitative role
and supported the NNP implementation process especially by
strengthening capacities in the implementation structures at
national and sub-national levels. Furthermore, as requested by the
Government, immediate technical support was provided to the
Nutrition Case Team by contributing to some specific deliverables
such as Terms of References, sections of the Implementation
Guidelines, progress markers, meeting reports and other products.
In Uganda, we have worked at strengthening and supporting the
country-owned, country-led UNAP implementation process;
fostered common understanding and stakeholder appropriation of
UNAP; and at the district level, we have worked on developing a
consensus model for UNAP operations.
The way forward for the partnership in both countries is to
continue supporting the implementation of NNP and UNAP
through building capacities at national and subnational levels; and
to foster learning and common understanding, while capitalizing
on our unique boundary crossing and facilitator roles to continue
stimulating cross-country fertilization by documenting and
disseminating lessons learned.
11
Advocacy and support for placing food security and nutrition at the centre of the government agenda.
Improved data collection and data management. At the regional level, a two-year regional support plan (to reinforce country actions) is being drafted. Its priority areas are: (1) Strengthening of Early Warning/Early Actions; (2) Ensuring quality and scale in joint food and nutrition action planning; (3) Supporting the response to refugees; and (4) Resourcing and advocacy. Delivery mechanisms have been identified for each priority as well as a convener and participating agencies. In January 2015, the Regional Support Plan will be disseminated to donors along with a Regional Investment Case that highlights priority areas to support joint advocacy for the food security and nutrition response in the Horn of Africa.
Nutrition Digest A quick overview of selected literature issued monthly
The authors estimated the benefit-cost ratios for nutriton-specific interventions by reviewing the evidence around pathways
in which stunting may generate economic losses though the following: 1) loss in physical growth potential, 2) cognitive
impairments and 3) increased risk of chronic diseases. Despite conservative assumptions used by the authors, all estimated
benefit-cost ratios are >1.0. Estimates ranged from 3.6 in the DRC to 48 in Indonesia, with a median of 18 in Bangladesh.
Hoddinott, J., H. Alderman, J. R. Behrman, L. Haddad and S. Horton (2014). The economic rationale for investing in stunting
reduction. Maternal and Child Nutrition 9 (Suppl 2):69-82
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The authors examined 44 coverage assessments from 21 countries to identify barriers to access to severe acute
malnutrition (SAM) services and understand how they vary according to context. The analysis found that the five most
commonly reported barriers to access across all interventions were: 1) Lack of knowledge of malnutrition; 2) Lack of
knowledge of the programme; 3) High opportunity costs; 4) Distance to site; and 5) Previous rejection. All the barriers were
found also to have influenced public health programmes.
Puett, C. Hauesnstein Swan, S. and Guerrero, S. (2013). What factors influence access to community-based treatment of
severe acute malnutrition? Access for All, Volume 2: (Coverage Monitoring Network, London, November 2013)
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The period between 6 and 24 months of age is a critical time in the growth of an infant. Therefore, complementary feeding
(CF) during this period needs to be timely, adequate, appropriate and sufficient in quantity. This study assessed the impact
of CF education on growth among children under 2 years of age and shows that CF education alone significantly reduced
rates of stunting (RR 0.71; 95% CI 0.56 to 0.91). Community-based nutrition education (including home-based dietary
counselling with messages that are culturally appropriate) combined with appropriate CF (utilizing locally available and
affordable nutrient dense foods) are needed to improve the nutritional status of children.
Lassi, Z.S., et al. Impact of education and provision of complementary feeding on growth and morbidity in children less
than 2 years of age in developing countries: a systematic review. BMC Public Health 2013; 13 (Suppl 3): S13.
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Increasing economic growth as a national policy is often justified for improving population health and nutrition in develop-
ing countries on the assumption that increasing per-capita will improve access to and consumption of goods and services
which in turn will improve nutritional status. This study challenges this assumption and emphasizes the need for direct in-
vestments in health and nutrition. Experiences from countries show that reduction in undernutrition can be accelerated
but that this will need deliberate action in prioritizing investment in the scale up of nutrition-specific interventions and
shaping national development processes to maximize nutrition sensitivity.
Vollmer, S., et al. (2014) Association between economic growth and early childhood undernutrition: evidence from 121 De-
mographic and Health Surveys from 36 low-income and middle-income countries. Lancet Global Health 2014; 2: e225-34.
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In 2013, the World Health Assembly endorsed the Comprehensive Implementation Plan (2012-2025) on Maternal, Infant
and Young Child Nutrition which included a global target for stunting, i.e. to reduce the number of stunted under-five
children by 40% by 2025. In 34 countries that have a high burden of stunting, scaling up the 10 nutrition-specific high
impact interventions to 90% coverage can result in overall reduced stunting by only 20%. Nutrition-specific interventions
alone are almost certainly insufficient; hence the importance of ongoing efforts to foster nutrition-sensitive development
and evidence based, multisectoral plans to address stunting at national scale.
De Onis, M, et al. The World Health Organization’s global target for reducing childhood stunting by 2025: rationale and
proposed actions. Maternal and Child Nutrition 2013; 9 (Suppl 2): 6-26.
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This Cochrane review is the first one looking at the impact of WASH interventions (to improve water quality and supply,
provide adequate sanitation and promote handwashing with soap) on the nutritional status of children under the age of 18
years. The review provides evidence that WASH interventions may slightly improve height growth in children under five
years of age. On the basis of both empirical and theoretical evidence, comprehensive WASH interventions that affect the
physical and behavioral environment in which a child grows and plays should continue to play a critical role in the
prevention of early childhood diarrhea and, thereby, in improving child nutrition and development.
Dangour, A.D, L. Watson, O. Cummings, S. Boisson, Y. Che, Y. Velleman, S. Cavill, E. Allen, R. Uauy (2013). Interventions to
improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children
(Review). Cochrane Database of Systematic Reviews Issue 8. Art. No.: CD009382.
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The authors of the two papers have searched through reviews and studies on whether and how agriculture can have
positive benefits for nutrition and health, particularly among mothers and children. The evidence base for the relationship
between agricultural change and improved nutrition is poor. The current lack of evidence does not mean that agriculture
does not support gains in nutrition and health, rather that the evidence of positive impact is still weak. It is critically
important for planners to explicitly include nutrition outcomes and indicators in agricultural programmes so that special
attention can be paid to identifying nutrition outcomes and in considering them during evaluations.
Meeker, J., L. Haddad. A state of the art review of agriculture-nutrition linkages. AgriDiet; 2013. Webb, P. Impact pathways
for agricultural research to improve nutrition and health: Literature analysis and research priorities. FAO and WHO; 2013.
JULY
The authors reviewed the main barriers and enabling factors affecting six types of large-scale maternal nutrition
programmes in field conditions. The six programme types included salt iodization; flour fortification; micronutrient
supplementation; nutrition education, and conditional cash transfers. This study shows that the key elements for
successful scaling up vary in importance depending on the specific maternal nutrition programme and the context in which
it operates. Programme designers need to think ahead about possible critical barriers for a given programme which in turn
can help to prioritize actions. Incorporation of equity considerations and investment in quality monitoring and evaluation
frameworks are also important.
Victora, C. G., et al. Scaling up maternal nutrition programs to improve birth outcomes: A review of implementation issues.
Food and Nutrition Bulletin 2012; 33 (Suppl): S6-26.
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Brazil’s Bolsa Familia Programme (BFP), the world’s largest conditional cash transfer (CCT) programme, has already been
shown to effectively reduce stunting and underweight among children under 5 years of age (Paes-Sousa, 2011). The
current study assessed the effect of BPF on under-5 mortality rates – and further reinforces the findings that this CCT
supports nutrition security by concluding that the decrease in mortality rates was largest among the malnutrition-related
deaths. The effect of consolidated BFP coverage was highest on under-5 mortality resulting from malnutrition (RR 0.35;
95% CI 0.24-0.50) followed by mortality resulting from diarrhea (RR 0.47; 0.37-0.61).
Rasella, D., R. Aquina, C.A.T. Santos, R. Paes-Sousa, M.L. Barreto. 2013. Effect of conditional cash transfer programme on
childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet; 382: 57-64.
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Among the targets set during the 65th World Health Assembly was a commitment to halve anaemia prevalence in women
of reproductive age by 2025 from 2011 levels. In this study, the authors estimated 1995 to 2011 trends in distribution of
haemoglobin concentration for children aged 6-59 months and for women of reproductive age (15-49 years) by pregnancy
status. In both 1995 and 2011, central and west Africa and south Asia had the lowest mean concentrations of haemoglobin
and the highest anaemia prevalence; east Africa had low haemoglobin concentrations for children. Mean haemoglobin
concentrations declined and anaemia prevalence have increased in children in southern Africa.
Stevens, G. A., M. M. Finucane, L. M. De-Regil, C. J. Paciorek, S. R. Flaxman, F. Branca, J. P. Pena-Rosas, Z. A. Bhutta, M.
Ezzati, on behalf of Nutrition Impact Model Study Group (Anemia) (2013). Global, regional, and national trends in
hemoglobin concentration and prevalence of total and severe anemia in children and pregnant and non-pregnant
women for 1995-2011: a systematic analysis of population-representative data. Lancet Global Health 1: e16-24.
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Worldwide, the prevalence of overweight and obesity combined increased by 27.5% for adults and 47.1% for children
between 1980 and 2013. The proportion of adults overweight or obese increased from 28.8% (95% UI 28.4-29.3) to 36.9%
(36.3-37.4) in men, from 29.8% (29.3-30.2) to 38.0% (37.5-38.5) in women. Among children and adolescents under 20 years
of age, the increase have been from 8.1% (7.7-8.6) to 12.9% (12.3-13.5) in boys and from 8.4% (8.1-8.8) to 13.4% (13.0-
13.9) in girls.
Ng, M., T. Fleming, M. Robinson, et al. (2014). Global, regional, and national prevalence of overweight and obesity in
children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384:
766-81.
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