Nutrition and National Development

1. Nutrition and National Development Landscape Analysis Country Assessment Timor Leste July 2009

2. Content • Importanceofearlynutrition for nationaldevelopment • LancetNutrition Series: PackageofEffectiveInterventions • TheNutritionSituationin Timor Leste • LandscapeAnalysis • FindingsoftheCountryAssessment • Recommendations Timor Leste Landscape Analsyis

3. Importance of Nutrition for National Development • Maternal and child undernutrition (low birth weight, stunting, wasting, micronutrient deficiency) = 35% ofallchilddeaths • Maternal anaemia = 20% of Maternal Mortality • Stuntingprocess • Startsinuterusandalloverby 2 yearsof age • Heightat 2 years determines final adult height (NOT GENETICS) Timor Leste Landscape Analsyis

4. Theimportanceofearlynutrition for nationaldevelopment Short term Long term Brain development Cognitive and educational performance Nutrition in uterus and early childhood Growth and muscle mass Body composition Immunity Work Capacity Diabetes, Obesity Heart Disease High blood pressure Cancer, stroke, and ageing Metabolic programming of glucose, lipids, protein Hormone/receptor/gene Death Short and long term effects of early nutrition (James et al 2000)

5. Timor Leste Package of Essential InterventionsEvidence-based interventions, Lancet Nutrition series Maternal and birth outcomes • Iron folate supplementation • Maternal supplements of multiple micronutrients • Maternal iodine through iodized salt • Maternal food supplements • Maternal deworming in pregnancy • Intermittent preventative treatment of malaria • Insecticide treated bednets Newborn babies • Promotion of breastfeeding • Delayed cord clamping Infants and children • Promotion of breastfeeding • BCC for improved complementary feeding • Zinc in management of diarrhoea • Vitamin A supplementation • Universal salt iodization • Handwashing or hygiene interventions • Treatment of severe acute malnutrition • Conditional cash transfer programmes (with nutritional education) • Deworming • Iron fortification and supplementation • Insecticide-treated bednets Timor Leste Landscape Analsyis

6. Timor LestePackage of Essential InterventionsEvidence-based interventions, Lancet Nutrition series Lancet Nutrition series global analysis: • These interventions are effective in reducing malnutrition • If implemented at high coverage, these interventions would: • Reduce all child deaths by one quarter in the short term • Reduce prevalence of stunting at 36 months by one third, • Conception through 24 months is the critical window of opportunity to prevent and intervene to reduce stunting Timor Leste Landscape Analsyis

7. Timor Leste NutritionSituation

8. Timor Leste Nutrition Situation Red line indicates cut off level for blanket supplementary feeding in emergency situations, 15% wasting

9. Timor Leste Nutrition Situation • 37.7% of women 15-49y = BMI<18.5* • 31.5% anaemic* • Fertility: 6.95 (2002-2004, 2004 Census) • Median age at first birth - 21 years* • Teenage pregnancy or motherhood (15-19yrs) – 14.5%* • MMR = 660/100,000 live births** • 20% households are food insecure and a further 23% highly vulnerable to becoming so** *DHS 2004 ** Census 2004; HSSP

10. Key Challenges at National Level Getting nutrition on the national agenda Acting at scale 1 4 Doing the right things Reaching those in need 2 5 Not doing the wrong things Using data for nutrition decision-making 3 6 Building strategic and operational capacity 7

11. Aim of Landscape Analysis and Country Assessment • The Landscape Analysis: multi-agency effort led by WHO and funded by BMGFwiththe objective ofmobilizingresources to help scale up effective nutrition action in the high-burden countries to accelerate achievement of MDGs 1, 4 and 5 • Country Assessments are to help countries understand how to scale up essential nutrition actions by carrying out a self assessment of “readiness“ to act at scale • Readiness = committment and capacity • The product is a set of reccomendations to government on how to increase rediness to act at scale • Key Audiences are: Ministry of Health, Ministries of Finance, Planning. Agriculture, other stakeholders, Development Partners

12. Country assessment • Burkina Faso (May 2008) • Ghana (July 2008) • Guatemala (June 2008) • Madagascar (March/April 2008) • Peru (August 2008) • South Africa (Feb – May 2009) ………… • Comoros (April 2009) • Timor Leste (June/July 2009)* • Ethiopia, Mali, Niger, Rwanda (planned in 2009) * NOTE: First country in Asia Timor Leste Landscape Analsyis

13. Process of Country Assessment • External team: Roger Shrimpton, Stephen Atwood, Karen Codling • National team: Staff from Alola, FAO, TAIS, UNICEF, WFP, WHO • Visits to Alieu, Baucau, Covalima, Dili • District Health Office, CHCs, HPs • NGOs and private clinics • Interviews with national stakeholders in Dili • National Committee for Finance, Promocao da Iqualdade, Ministry of Health, Ministry of Agriculture, Alola, TAIS, World Vision, UNICEF Timor Leste Landscape Analsyis

14. Findings and Recommendations Timor Leste Landscape Analsyis

15. Understanding of causes of malnutrition: Findings Common perception is: • Due to food shortages • Due to inadequate knowledge • Due to poverty Very little understanding that it is: • Poor maternal health and nutritional status including high fertility  stunting pre-programmed in utero • Poor breastfeeding and complementary feeding practices • High incidence of infectious diseases • Household food insecurity Timor Leste Landscape Analsyis

16. Positioning Nutrition on National Agenda:Findings • Consequences for national development not sufficiently recognized • Not specified as a National Priority in NDP • Under 4th priority of Social Protection and Social Services • Caused by other priorities (Agriculture and Food Security) and contributes to other priorities (Rural Development and Human Resources Development) • Not recognized as a responsibility of sectors beyond health • Not prioritized by Finance, Planning etc. Note: Despite fact that malnutrition levels are among the highest in the world Timor Leste Landscape Analsyis

17. Improving status of nutrition on national agenda:Recommendations • Advocacy and awareness raising on causes and consequences of malnutrition at most senior level • Showing linkages between nutrition, achievement of the MDGs and national development • Calculating the cost-benefit of nutrition interventions • Establishment of high level, multi-sectoral nutrition council • Establish nutritional status (stunting) as key indicator of national development Timor Leste Landscape Analsyis

18. Coordination for Nutrition:Findings • No policy level coordination • Reasonable technical coordination: • Nutrition working group at national level • Some coordination mechanisms at district level • Support from central to district level could be improved Timor Leste Landscape Analsyis

19. Human Resource Availability:Findings • Human resource situation improved • Nutrition unit now a Department • Nutrition coordinators newly established in most districts but not regular staff • People with responsibility for nutrition in some CHCs • Multiple NGOs contributing personnel and resources to nutrition Timor Leste Landscape Analsyis

20. Coordination and Human Resource Availability:Recommendations • Establishment of high level, multi-sectoral nutrition council • Regularize District Nutrition Coordinator positions Timor Leste Landscape Analsyis

21. SISCa:Findings • Major new government thrust for improving community access to health services • More than 500 established posts and more than 14,000 PSFs • Coverage at this stage remains very low • Lack of use of vital registry for identifying clients • Issues of remuneration of PSFs Timor Leste Landscape Analsyis

22. SISCa:Recommendations • Establish a mechanism for sustainable work of PSF beyond the SISCa day • Implement the SISCa guidelines for vital registration to list all clients • Accelerate establishment of KJPS to mobilize community for SISCa attendance and support registration • Develop concept of actively searching for those who don’t attend • Expanded SISCas every six months including screening for underweight, vitamin A, deworming • Focus of nutrition table on counseling and nutrition education rather than weighing Timor Leste Landscape Analsyis

23. Nutrition Activities:Findings • Primarily identified as weighing and supplementary feeding • Incomplete recognition of importance of below as nutrition interventions: • Breastfeeding promotion and support • Disease prevention and treatment • Micronutrient deficiency prevention and treatment • Interventions to reduce maternal malnutrition Timor Leste Landscape Analsyis

24. Child Weighing:Findings • Takes up majority of time and resources • Low coverage: • National monthly average for 0-2 years only 25% in 1st quarter 2009 • Even less attend monthly • Not used as a tool to assist/facilitate counseling • Only used to support supplementary feeding • Dissatisfaction of both health workers and community “why do you keep weighing our children – we know the problem but you do nothing about it” Timor Leste Landscape Analsyis

25. Supplementary Feeding:Findings • Has come to be the main reason to attend health facilities • Incorrect administration of protocols • Potentially not improving nutrition because: • Consumed by whole family, not only malnourished members • Used as an income substitute • Problems of storage and quality • Problems of poor education on preparation and cooking Timor Leste Landscape Analsyis

26. Replace regular child weighing with more effective interventions:Recommendations • For data collection  periodic surveillance/screening or sentinel sites • For identifying malnourished for treatment (supplementary feeding)  periodic screening • For identifying malnourished or faltering for counseling  counsel all (prevalence of UW and/or faltering > 60%) Timor Leste Landscape Analsyis

27. Replace regular child weighing with more effective interventions: Recommendations • Weigh all children once/twice per year to measure prevalence of underweight (eg during vitamin A distribution) • Screen with MUAC children >23 months monthly per year to identify those in need for supplementary feeding • Counsel mothers of all children – by age group • Promote and support breastfeeding • Improve quality and frequency of complementary feeding • Improve care for prevention and treatment of illness Timor Leste Landscape Analsyis

28. With time and resources saved from child weighing: • Counsel women on importance of birth spacing for improved nutrition of mothers and children • Counsel pregnant and reproductive age women and their families on maternal nutrition • Distribute iron-folate or multiple micronutrients and deworming to (i) women 18-23 years and (ii) reproductive age women • Deworm pregnant women (2 x in 2nd and 3rd trimester) • Prevent and treat illness such as malaria, TB in pregnant and lactating women • Improve implementation of vitamin A supplementation in post-partum women Timor Leste Landscape Analsyis

29. Simplify supplementary feeding:Recommendations • Screen using MUAC only • Provide to all pregnant and lactating women • Develop and use locally produced commodities • Consider replacing with conditional cash transfers in food secure areas Timor Leste Landscape Analsyis

30. Data Management and Use:Constraints Problems with denominators at local level: • Discrepancy between census estimates of total population and district targets. • CHC, HP (and some DHS) do not have denominator. • HP does not enumerate catchment area • HP worker / CHC midwife not able to calculate malnutrition percentages accurately. Timor Leste Landscape Analsyis

31. Data Management and Use:Constraints • Data on ‘weight for age’ is passed along to District and National level, not used for local planning or interventions. • Registers for recording are complicated and excessive • Not all data needs to be reported to higher level. Timor Leste Landscape Analsyis

32. Data Management and Use:Recommendations • Health Post Staff should use available household maps (or develop their own as per SISCa instructions) of catchment areas to locate, visit and enumerate all household members and use this as denominator. • Use these numbers as officially accepted targets for Health Post activities and service provision. Timor Leste Landscape Analsyis

33. Data Management and Use:Recommendations • Identify nutrition indicators appropriate for collection through HMIS as opposed to data collected in surveys. • Capacity development (training) is needed at all levels in how to use data for decision making. • Request new post of ‘Statistician’ at DHS office who will rotate through CHCs to compute necessary descriptive statistics or identify gaps. Timor Leste Landscape Analsyis

34. Data Management and Use:Recommendations • Identify data needed for decision making at each level, not necessarily for national reporting. • Develop simplified recording system (with reduced number of registers) at health facility level. Timor Leste Landscape Analsyis

35. Human Resource Capacity:Constraints • Not all Nutrition Coordinators / Focal Points in Districts visited have sufficient knowledge of nutritional subjects to serve as resource persons. • Training in nutrition has not reached all Nutrition Coordinators / Focal Points nor staff in DHS, CHC, or HP. • Training materials and technical references are not available in the DHS, CHC or HP. • Supportive Supervision from Center to Districts or from Districts to sub-districts is inadequate. Timor Leste Landscape Analsyis

36. Human Resource Capacity:Constraints • Staff in DHS, CHC, HP do not feel sufficiently confident about nutrition knowledge to serve as adequate source of information for the community; many spontaneously requested more training in specific nutrition subjects (e.g., breastfeeding, support to maternal nutrition). • With limited knowledge/exposure to nutrition subject matter, staff are unable to expand nutrition interventions beyond supplementary food, administration of vitamins. • Without reference materials or training, practices are irregular and not according to established standards. Timor Leste Landscape Analsyis

37. Human Resource Capacity:Recommendations • Focus initial training activities on Health Staff before focussing on community education. • On-going training needs of Nutrition Coordinators / Focal Points in position should be assessed and lead to intensive 1-2 week refresher training and continuing education plans. • Supportive supervisory visits from Center -> District, District -> sub-district should be facilitated and resourced. • Available Training materials / technical references to be distributed at DHS/CHC/HP for self-learning by staff. Timor Leste Landscape Analsyis

38. Human Resource Capacity:Recommendations • Determine availability of IEC materials and arrange for distribution to DHS/CHC/HP. • Do rapid training needs assessment of other health center staff and assist Nutrition Coordinators in developing local in-service training sessions. • Develop/distribute training materials in support of this. • Examine possibility of developing National Nutrition Training Course. Timor Leste Landscape Analsyis

39. Standard Operating Procedures:Constraints • Protocols at central level that standardize nutrition interventions and practices are not available at District, Sub-district level. • Staff develop local practices for nutrition interventions – some of them not in keeping with accepted standards; other practices are spread by word-of-mouth from staff who attended training. Timor Leste Landscape Analsyis

40. Standard Operating Procedures:Recommendations • Identify all protocols available, aggregate in SOP Nutrition Manual (loose-leaf, not bound), print and distribute to all DHS, CHC and HPs. • Review contents in DHS Monthly / Quarterly Meetings with DHS Director as Chair. • Nutrition Working Group identifies missing protocols and develops these for addition to the SOP Nutrition Manual. Timor Leste Landscape Analsyis