Good Practices and Lessons On Nutrition

1. The 4th Comprehensive Africa Agriculture Development Programme (CAADP) Partnership Platform Meeting Pretoria, 26-27 March Good Practices and Lessons On Nutrition

3. Role of Nutrition • Better nutrition is a prime economic growth and human wellbeing

4. Role of Nutrition • A. Adequate Nutrition stronger immunity • B. Stronger Immunity less illness & better Health. • C. Health Children learn better • D. Health Population more productive

5. Causes of child mortality worldwide >35% attributable to undernutrition

6. Relationship between nutrition and child survival Deaths associated with under-nutrition 60% Sources: EIP/WHO. Caulfield LE, Black RE.Year 2000

7. Child survival findings from the Lancet… • “…group of effective nutrition interventions, including breastfeeding, complementary feeding, vitamin A & zinc could save 2.4 million children each year (nearly 25% of the 10 million under-five deaths)” • The Lancet, 2003

8. Not only an issue of child survival • Nutrition is also important for: • Physical growth • Behavioral development, cognitive function • School attendance, performance • Ultimate income-generating capacity, economic development • Risk of non-communicable diseases

9. Overall Nutrition Situation

10. 9 countries in Africa are on track to meet the MDG 1 target

11. 178 million children under 5 suffer from stunting Prevalence of Stunting Black et al (Lancet 2008)

12. Emerging Issues • 1. food Insecurity • 2. low agricultural productivity • 3. Financial crisis • undernutrition.

13. Emerging issues - obesity • 8 out of the top 20 countries in overweight prevalence among children <5 are in Africa • Double burden of overweight and underweight: e.g. Djibouti: high overweight, wasting & stunting

14. Interventions to prevent nutritional stunting and underweight • Pre-natal: • Improved maternal nutrition and health before and during pregnancy to improve maternal survival and pregnancy outcome, reduce LBW and nutrition related chronic diseases later in life. • Post-natal: • Protection, promotion and support of optimal BF; • Adequate complementary feeding (timing, amount, animal source foods); • Prevention and appropriate nutritional management of infections (diarrhea, HIV, malaria, TB others) and SAM, MAM; • Selected MNs: vitamin A, iodine, iron folic acid, zinc; • Psycho-social stimulation; • Healthy life style – food, physical exercise and health.

15. Impact of vitamin A on child mortality Overall 23% reduction in child mortality with vitamin A supplementation Indonesia India Nepal Africa

16. Vitamin A supplementation (%, full coverage for 6-59 month old children) Eastern and Southern Africa Source: UNICEF Global Database, Nov 2008

17. Optimal breastfeeding 0-6 months Key Messages Early initiation of breastfeeding (within1 hour of birth) Exclusive breastfeeding until 6 months Breastfeed day and night at least 10 times Correct positioning & attachment Empty one breast before switching to the other Estimated decrease of child mortality: 13% WHO Infant & Child Feeding Recommendations, 2001

18. Exclusive breastfeeding rates <6 mos in ESAR - 6 countries (above 50%) * Source: UNICEF SOWC 2009

19. Burden of non-exclusively breastfed children, ESAR Source: UNICEF database 2008

20. Success Stories: IYCF

21. Sharp improvements in EBF are possible! Source: PFC 2007 & SOWC 2009

22. A comprehensive approach results in these sharp improvements in EBF rates • How: through implementation at scale of a comprehensive, context-specific approach to IYCF at all levels: • Most countries don’t have comprehensive approach, and don’t implement at scale. Challenges faced can be overcome. • Promotion,support and protection of breastfeedingneed to go together • Promotion = comprehensive evidence-based communication strategy; • Support = trained HW and counselors and community based support structures; • Protection = Code and maternity protection • Implementation of “quick wins” toreach the “low hanging fruit”: • e.g. on giving water before six months

23. 5 action areas of a comprehensive IYCF strategy(breastfeeding and complementary feeding) • National level actions (policy, legislation, planning, budget, M&E) • Health system level actions • Community level actions • Communication for development • IYCF in especially difficult circumstances including emergencies and HIV

24. Evidence-based activities • Maternity care practices: Institutional changes in maternity care practices have been shown to effectively increase breastfeeding initiation and duration rates • Professional support:professional counsellors shown to be most effective in extending the duration of any breastfeeding • Lay and peer support:Lay counsellors shown to be most effective in increasing the duration of exclusive breastfeeding • Community based breastfeeding promotion and support: five studies in developing countries provide evidence that various types of community based breastfeeding promotion and support can improve breastfeeding practices in developing countries. Large scale programmatic experience & results documented in 10-country case study. • Media and social marketing: A Cochrane review suggests that media campaigns have been shown to improve attitudes towards breastfeeding and increase initiation rates. Social marketing has been established as an effective behavioural change model for a wide variety of public health issues • Support for breastfeeding in the workplace: Evidence from industrialized countries has shown how workplace support programmes increases the duration of breastfeeding

25. A quick win: targeting water in Ghana 1998 More progress possible if target water & CF 2003 1993

26. Malawi: from 3 to 56% through a comprehensive approach

27. Vitamin A Supplementation

28. Main Findings CHDs achieved high coverage (above 80%) of VAS bi-annually, and led to increase in VAS coverage ranging from 15 to 90 ppts High coverage (above 80%) of de-worming was achieved, resulting to significant increase as it was not delivered through other means prior, while measles immunization increased by about 10 ppts The impact of CHDs on vitamin A deficiency could be estimated quantitatively in only Ethiopia and Zambia, as data for the other countries were incomplete. There were substantial falls in low serum retinol (in Zambia among children six to fifty-nine months old they fell from 66 per cent in 1997 to 54 per cent in 2003) and night blindness (in selected regions of Ethiopia) among children six to fifty-nine months it declined from 4.0 per cent in 1996 to 0.8 per cent in 2005, most likely attributable to VAS/CHDs. Based on known efficacy studies, this is expected to reduce significantly child mortality rates in these countries. Vitamin A+ delivery throughChild Health Days in Ethiopia, Madagascar, Tanzania, Uganda, Zambia and Zimbabwe

29. Universal Salt Iodization

30. UNICEF supported documentation of country experiences has shown that the essential requirements of successful USI programmes are: High-level government commitment, reflected in evidence-based national policy legislation and standards, and allocation of sufficient resources for continuous consumer education on the damage of IDD to brain development and benefits of iodized salt consumption, regular monitoring and enforcement; Buy-in by salt producers, wholesalers and retailers; Consumers who know about IDD and demand for iodised salt; A national coalition to monitor implementation and enforcement of laws. Successes and challenges on IDD elimination in Burundi, Kenya, Madagascar, Rwanda, Uganda, Zimbabwe

31. Scale-Up of IMAM

32. Scale-up of community management of acute malnutrition: Ethiopia and Malawi • Community management of acute malnutrition (CMAM), comprehensive system for identifying, referring, and treating children with acute malnutrition: • Community-based screening, • Referral to appropriate level of care, based on degree of wasting and presence of complications; • Specific treatment protocols, food supplements, medicines; • M&E, supply management. • Ethiopia implementing largest IMAM program ever – target to reach 100,000 new admissions/month • Malawi close to reaching countrywide coverage. • Somalia/Madagascar/Uganda piloting uses of RUFs for moderate malnutrition

33. UNICEF contribution to the UN comprehensive framework for action • Outcomes to meet immediate needs • • Emergency food assistance, nutrition interventions and safety nets enhanced and made more accessible; • • Smallholder farmer-led food production boosted; • • Trade and tax policy adjusted; • • Macroeconomic implications managed. • Outcomes to build longer-term resilience and contribute to food security • • Social protection systems expanded • • Growth of smallholder farmer-led food availability sustained; • • International food markets improved; • • International bio-fuel consensuses developed. • Global information and monitoring systems strengthened

34. Challenges, conclusions, • and recommendations, opportunities

35. Challenges to scale-up • Placing malnutrition prevention/control at the centre stage in the development and political agenda • Adequate nutrition human resources base at the key levels and across sectors • In-country technical capacity for nutrition (very few nutritionists, especially French and Portugese speaking) • Mainstreaming nutrition into either pre-service and in-service training • Sustainability and Government ownership. • Lack of funds for critical interventions • Quality control, monitoring and impact evaluation of the food fortification programme, routine quality data collection on IYCF core indicators

36. Challenges to success • Inter-sectoral communication, coordination, consistent messages: • Health • Social Welfare • Agriculture • Education • Economics & industrial development • Community & women’s development • Effective delivery platforms for community outreach (training, motivation, supervision) • Effective BCC strategies • Nutrition training and applied research capacity • Sustained financing mechanisms for at least 5-10 years.

37. Conclusions and recommendations • Adequate nutrition is essential for child survival, physical growth and development, and future economic capacity, hence directly relevant for achieving MDGs • Key nutrition strategies are available to reduce malnutrition and related complications: • Maternal supplementation during pregnancy; • Protection, promotion and support of optimal BF practices; • Timely introduction and responsive feeding of adequate amounts of high quality CFs; • Nutritional management of infectious diseases (diarrhea, HIV, malaria, TB others) and SAM, MAM; • Selected MNs (supplementation, fortification, promotion of diversified diets) – vitamin A, iodine, Iron folic acid, zinc etc. • The investment in nutrition should be based on costed comprehensive nutrition plans of action, with the aim of accelerating progress towards MDGs and targeting high vulnerable populations affected by food and economic crisis and the ongoing HIV Pandemic.

38. Opportunities • Overwhelming scientific evidence on the significance of nutrition for maternal, newborn and child survival and development (Lancet series), and for national social and economic development • Rich country experiences on what has worked • Commitment to revitalize agriculture and food security, in therefore need to ensure that nutrition is central core. • Partnership building on nutrition and food security, targeting key vulnerable groups – urban and rural poor, smallholder farmers - women, HIV affected and infected