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

Childhood Stunting ColloquiumWHO, Geneva

14 October 2013

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!

REACH is an inter-agency partnership that promotes a country-led, multi-sectoral approach to addressing undernutrition

Intense support

Moderate support

Remote support

Interested &/or emerging

Objective: Reduce child undernutrition

• 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

REACH contributes to the "UN delivering as One"

SectorsS

ocia

l Pro

tectio

nAg

ricu

ltu

re

Multi-stakeholder platform

Country

government

FP Donors

UN

Ag

en

cie

s

Civil

Society

It catalyses multi-sectoral collaboration between UN Agencies, governments and civil society to combat child undernutrition

REACH applies a Theory of Change to accelerate progress towards MDG1, target 1C

Source: REACH Secretariat

If we address

these issues …

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

with these

strategies to improve

governance…

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

then we can

achieve …

Political support to

fund programs and

coordinated nutrition

efforts

this impact

Improved

nutrition for

women and

children

Nutritional impact and

coverage

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

Source: REACH Secretariat

If we address

these issues …

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

with these

strategies to improve

governance…

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

then we can

achieve …

Political support to

fund programs and

coordinated nutrition

efforts

this impact

Improved

nutrition for

women and

children

Nutritional impact and

coverage

Action spans beyond 2015 as hunger remains a problem, and nutrition issues

gain a stronger emphasis in the post-2015 agenda

Wasted children <5Wasted children <5

0

20

40

60

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

Underweight children <5Underweight children <5 Stunted children <5Stunted children <5

0

5

10

15

67% 56.8%

44.4%

12.3% 12.3%

0

10

20

30

40

50

1992*

Other NS

2005*

DHS

2000*

DHS

23.8%

%

42.8% 42.8%

34.4%

MDG

target

28.7%

2011

DHS

1992*

Other NS

2005*

DHS

2000*

DHS

2011

DHS

52.2%

1992*

Other NS

2005*

DHS

2000*

DHS

2011

DHS

9.7%

N/a

*Note: Prevalence recalculated using 2006 WHO growth standards

DRAFT

%

%

WHO

threshold

30%

WHO

threshold

40%

WHO

threshold

15%

Identify the scope and magnitude of nutrition problems, illustrating how they have changed over time (Ethiopia)

Highest %

Compare prevalence with absolute numbers, by region, to inform planning and prioritisation exercises (Nepal)

Highest #’s

20-29.9%Far-western

Eastern

Central

Western

Mid-western

Stunting among children <5 years old, 2011

30-39.9%>40%

Prevalence of stunting

37%38%37%50%46%

261,262425,250232,564235,926162,018

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)

Highest

Largest absolute numbers of malnourished children in Northern region…

Largest absolute numbers of malnourished children in Northern region…

But stunting has decreased in North, while increasing in Southern and Eastern regionsBut stunting has decreased in North, while increasing in Southern and Eastern regions

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.

Stunting prevalence of children 6-59 months, 2010

34.5%

Lowest

39%

39.6%22%

109,000 children

44,000 children85,000 children

89,000 children

Change in stunting prevalence, 2008 - 2010

-5+% +15+%

IncreaseDecrease

0

West Urban

West Rural Moyamba

Bonthe

Pujehun

BoKenema Kailahun

Koinadugu

Tonkolili

Bombali

Port Loko

Kambia

Kono

Summarise the nutrition situation from A to Z(Iringa Region, Tanzania)

Requiring action

Serious problem requiring urgent action

Not currently a serious problem

Not applicable

DRAFT

↑↑↑↑ Improving ↓↓↓↓ Deteriorating →→→→ No Change

Indicator URBAN Severity Trend RURAL Severity Trend

Nutritional Im

pact

Stunting Prevalence of stunting among children 6-59 mo. old 35.0 % ↓↓↓↓ 45.5% ↑↑↑↑

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.

Underlying Cau

ses

Food Security Households with poor or borderline food consumption - - - - - - - - - - - -

Global Hunger Index Score - - - - - - - - - - - -

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 % ↑↑↑↑

Basic Cau

ses

Education Females that completed primary school or higher 49.0% ↑↑↑↑ 11.2% ↑↑↑↑

Females 15-49 yrs. who are literate 67.8 % ↑↑↑↑ 25.5 % ↑↑↑↑

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 % - - ↑↑↑↑

GINI Index - - - - - - - - - - - -

Not currently a serious problemRequiring action

Urgent Problem requiring urgent action

Not applicable SEVERITY TRENDS

Underscore any marked disparities e.g. rural/urban divide, gender… (Mozambique)

What can be done?

What does multi-sectoral action really mean?

REACH applies a Theory of Change to accelerate progress towards MDG1, target 2

Source: REACH Secretariat

If we address

these issues …

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

with these

strategies to improve

governance…

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

then we can

achieve …

Political support to

fund programs and

coordinated nutrition

efforts

this impact

Improved

nutrition for

women and

children

Nutritional impact and

coverage

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 sector-specific action and opportunities for integrated action

… in a logical and synthesised manner

Potential actions1

What d

Food Consumption2

•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

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

Food, agriculture & diets Health-based

Capacity development * Nutrition education & social marketing

Infant & Young Child Feeding

•Breastfeeding promotion & support

•Complementary feeding & support

•Infant feeding in context of HIV

Hygiene

•Personal hygiene promotion

•Food hygiene & preparation

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

Maternal & child care

In-kind Transfers

•General food distribution

•Blanket Supplementary Feeding

•Food-for-assets/training

•School feeding

Cash & Vouchers

•Cash/Vouchers-for-

work/training/education

•Conditional cash transfers

Other Social Protection

•Public works

•Maternity/paternity protection

•Subsidies/taxes

Social protection

1. Each country’s NNP is specific to the country’s situation and therefore a selection of tailored actions is pursued2. Action Sheets being developed for the thematic areas marked in bold, italic text under the four respective categories Source: REACH Secretariat

Developing ‘Action Sheets’ on nutrition-related actions for thematic areas, including nutrition-sensitive, that transcend institutional mandates

Conte

xt a

ssessm

ent �

Do n

o h

arm

�E

quity �

Wom

en’s

em

pow

erm

ent �

Multi-secto

ral colla

bora

tion �

M&

E (

exp

licit n

utr

itio

n o

utc

om

es &

indic

ato

rs)

REACH applies a Theory of Change to accelerate progress towards MDG1, target 2

Source: REACH Secretariat

If we address

these issues …

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

with these

strategies to improve

governance…

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

then we can

achieve …

Political support to

fund programs and

coordinated nutrition

efforts

this impact

Improved

nutrition for

women and

children

Nutritional impact and

coverage

Action spans beyond 2015 as hunger remains a problem, and nutrition issues

gain a stronger emphasis in the post-2015 agenda

How are we doing?

REACH applies a Theory of Change to accelerate progress towards MDG1, target 2

Source: REACH Secretariat

If we address

these issues …

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

with these

strategies to improve

governance…

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

then we can

achieve …

Political support to

fund programs and

coordinated nutrition

efforts

this impact

Improved

nutrition for

women and

children

Nutritional impact and

coverage

Action spans beyond 2015 as hunger remains a problem, and nutrition issues

gain a stronger emphasis in the post-2015 agenda

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

Once actions are selected and implemented, information systems/ tools needed to track progress (Mozambique)

Key

ProblemsIntervention areas Status Indicator Status Year Coverage Indicator Coverage Year

Ca

re

Po

or

IYC

F

Pra

ctic

es Exclusive

breastfeeding

% of children (0-5 months) exclusively breastfed

% of women who started timely initiation of breastfeeding

42.8

76.7

2011

2011

% of pregnant/lactating women receiving promotion on

exclusive breast feeding

- -

Complementary

Feeding

% of children 6-23 mo who fed according to IYCF practices 13.0 2011 % of mothers receiving education on complementary

feeding

- -

Ina

de

qu

ate

ma

tern

al

care

Family Planning % adolescents girls 15-19 using contraceptives

Median month interval between births between births

among women 15-49 yrs

8.4

34.8

2011

2011

% of adolescent girls 15-19 counseled on the use of

contraceptives

% of women 15-49 using contraceptives and declared

they want to wait 2 or more years to have their next

child

-

6.6 2011

Hygiene promotion % of children 6-59 mo with diarrhea 11.1 2011

% of households with a hand washing station equipped

with water and soap/cleansing material

% of children being treated with ORS and Zinc

31.7

-

2011

-

Distribution of

nutrition supplement% of pregnant women 15-49 yrs who are underweight - -. % of pregnant women receiving food supplements - -

He

alt

h a

nd

Sa

nit

ati

on

So

il,

wa

ter

bo

rne

en

de

mic

dis

ea

ses 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 months46.3* 2011

Healthcare

ANC% of pregnant women attending 4+ ANC visits

Median month of pregnancy for first ANC visit

50.6

5.4

2011

2011

% of women receiving IPT during pregnancy in ANC

% of pregnant women 15-49 yrs who during ANC

received counseling, were tested and received the

results for HIV

18.6

42.3

2011

2011

Mic

ron

utr

ien

t

De

fici

en

cie

s Vitamin A

Supplementation % of children with Vitamin A deficiency 68.8 2002

% of children 6-59 months receiving VAS in the past 6

months71.5 2011

Iron/folate

Supplementation % of pregnant women with anemia 50.9 2011

% of women who consumed iron/folate supplements for

90+ days during pregnancy25.9 2011

Distribution of MNPs % of children 6-59 mo with anemia 68.7 2011 % of children 6-59 mo receiving MNPs - -

Fo

od Insu

ffic

ien

t m

acr

o

an

d m

icro

nu

trie

nt

inta

ke

Iodized saltMedian urinary iodine level (µg/L) among school aged

children 6-12 yrs60.3 2004 % households consuming iodized salt 44.8 2011

Food Fortification% 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) - -

Nutrition Education % of households with poor or borderline food consumption 27.4. 2010% of children 6-23 mo consuming vitamin A rich foods

% of children consuming iron rich foods

71.0

45.2

2011

2011

Fo

od

Inse

curi

ty

Production of

nutritious foods

% of households consuming Iron rich foods

% of households consuming vitamin A rich foods

-

-.

-

-

% of households producing iron rich foods

% of households producing vitamin A rich foods

-

-

-

-

Appropriate processing

and storage

% 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 barn56.0 2009

Cash

transfers/subsidies% of income spent on food 51.4 2008 % of households that benefited from income transfer - -

Market

Centre

Drying

Floor

Well

Police

Post

Mosque

Church

Vocational

Centre

Community

Bank

PHU

School

Town

Crier

R O A D

Committees at village level

committees at Chiefdom or ward level

Village in Moyamba district, Sierra LeoneHow does Fatou’s household access/benefit from nutrition actions?

Thank you