The Double Burden of Malnutrition GCHB 6780 Roger Shrimpton John Mason Lisa Saldanha

1. The Double Burden of MalnutritionGCHB 6780Roger ShrimptonJohn MasonLisa Saldanha 20 February 2013 Class 10:Policy and Programmes for Prevention of DBM III

2. Content • Nutrition Capacity and Governance (DBM draft pp42-46) • Landscape Assessment of Readiness • LNS Country Assessment • Scaling Up Nutrition (SUN) • Governance structures • Capacity development • Monitoring and evaluation • Conclusions Readings: 15. Waters E, et al 2011. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 12:CD001871 (Jennifer) 16. Hite AH,et al . 2010 In the face of contradictory evidence: Report of the Dietary Guidelines for Americans Committee. Nutrition 26:915–924 (Amanda)

3. Landscape Analysis on Countries Readiness • A WHO led assessment exercise carried out in some 20 LMICs • Aim of Country Assessment • Help countries understand how to scale up essential nutrition actions • Assessing “readiness” = “willingness” & “capacity” • Prepare recommendations on how to strengthen readiness • Methodology • Mixed groups of assessors with “external” facilitators, • Desk analysis, focus group discussions, individual interviews at central, regional and district levels

4. Landscape Analysis on Countries Readiness Country assessment tools: • National level assessment • Policy-makers' perceptions on nutrition problems and their causes • Inter-sectoral coordination mechanism • Support provided by each Governmental Departments/Agencies involved in nutrition action/programmes, including • budgets for the last 3 year, • human resources for nutrition • Nutrition monitoring and surveillance and use of data for decision making • Advocacy efforts/needs • Regional/District level assessment - Players in nutrition action - Budgets and human resources for nutrition action - Nutrition programmes being implemented (i.e. Management of severe malnutrition, IMCI, BFHI, anaemia control.) - Training of personnel in nutrition - Nutrition assessment (which indicators are being collected) and application of nutrition data - Communication strategies to reach communities - Priority needs for scaling up action? (i.e. infrastructure, human resources, budgets, etc.)

5. Landscape Analysis on Countries Readiness Country assessment tools: • Facility structure checklist - Availability of nutrition education and communication materials and of supplies (i.e. functioning weighing scale, measuring board, MUAC tape, child health card, GM chart, iron/folate tablets, vitamin A capsule, therapeutic food, etc.) • Health worker interview tool • - Training received, Knowledge of nutrition protocols, Activities they implement, Relevance of training they received and current job/role they play, Support/training needs, Community involvement

6. Landscape Analysis on Countries Readiness Analysis plan: • Willingness to act (Commitment) • - Political commitment at central level • - Focused policies (and regulation) at central level • - Resource mobilization at central level • - Organization and management (incl. involvement of other stakeholders/partners) at central, regional/district levels • - Policies/protocols in support of the nutrition programmes at the national and subnational level • - Central level support to regions/districts • - Presence and adherence to protocols at facility level • - Budget provision at subnational level

7. Landscape Analysis on Countries Readiness Analysis plan: • Ability to act (Capacity) • - Distribution of staff with appropriate skills at all levels • - Capacity of staff at all levels • - Quality of services in facilities • - Staff motivation at all levels • - Follow-up and enhanced care plan • - Integration into other programmes • - Management systems • - Information systems • - Supplies and IEC materials • - Client knowledge/Satisfaction • - Community organizations

8. Landscape Analysis on Countries Readiness Major findings after 20 country (LMICs) assessments: • There are many nutrition partners and stakeholders at the country level that frequently meet in high level coordination forums • However the understanding of the extent and the nature of the problem is often missing • Although most countries have polices these are not translated into plans and programmes, with activities spelled out and with resources required • Although lots of nutrition data exists, very rarely is it collected and analyzed and used for decision making at any level. • The lack of human resource capacity for operationalzing the necessary nutrition action is a common theme across all countries Source: Nishida et al 2010

9. Lancet Nutrition Series 2008

10. Lancet Nutrition Series 2008

11. Scaling Up Nutrition (SUN): mobilizing financing for nutrition through other sectors • In countries most affected by undernutrition, there are little or no funds for nutrition programmes • World Bank Strategy (2006) tries to ensure that the funding needed to take to scale Essential Nutrition Interventions (ENI) is included in Poverty Reduction Strategy Papers (PRSPS) or National Development Plans. • The Bank Strategy proposed three key operational challenges to scaling up • 1) Building national commitment and capacity to invest in nutrition by (e.g. using “Profiles” to calculate costs of undernutrition); • 2) Mainstreaming nutrition in country strategies and programme approaches (e.g. Maternal Newborn and Child Health and in HIV/AIDS) • 3) Reorienting any existing large scale investments to maximize impact

12. Scaling Up Nutrition (SUN): mobilizing financing for nutrition through other sectors • A policy brief was prepared for Scaling Up Nutrition (SUN), which has become known as the SUN Framework and already has over a hundred global institutions endorsing it as signatories • The SUN Framework, builds on the WB Strategy and includes the Lancet Nutrition Series (LNS) ENI

13. Scaling Up Nutrition (SUN): mobilizing financing for nutrition through other sectors • The SUN Framework calls on all partners to scale up efforts against rising undernutrition by among other things: • 1) developing a coordinated, multi‐stakeholder approach; • 2) using the Paris Accra Principles of Aid Effectiveness; • for the harmonisation of donor procedures and practices so as to reduce transaction costs for partner countries. • 3) Mobilizing key stakeholders in an inclusive approach to country ownership, • 4) Use the “Three Ones”, namely: • One agreed overarching policy framework that provides the basis for coordinating the work of all partners; • One national coordinating authority; • One agreed national monitoring and evaluation system.

14. Scaling Up Nutrition (SUN): mobilizing financing for nutrition through other sectors • 5) Develop strong prioritized country nutrition strategies that while grounded in country specificity • take particular account of the “window of opportunity” of conception to two years of age, • be multisectoral linking agriculture and food security, social protection and public health, and • include elements of capacity development and monitoring and evaluation.

15. A Framework for Action for Scaling-Up Nutrition (SUN) Important opportunity for moving ahead collectively with a common vision, a common voice and a common approach.... A multi-partner effort, prepared with support from the Bill and Melinda Gates Foundation, the Government of Japan, UNICEF and the World Bank

16. SUN Framework endorsements

17. Mission of SUN “Through a coordinated effort that includes technical support, high-level advocacy and innovative partnerships, participants in the SUN Movement will improve people’s nutrition and so strengthen health and development. The SUN Movement is not a new initiative, institution or fund: instead it increases the effectiveness of existing initiatives and programmes by supporting national leadership for nutrition; encouraging focus and alignment of this support; and enabling the participation of a wide range of stakeholders to ensure broad ownership and shared responsibility for results.”

18. II. The Road Map SUN RoadMap: Operationalizing the Framework http://siteresources.worldbank.org/NUTRITION/Resources/SUNRoadMapSeptember2010.pdf

19. II. The Road Map Elements of SUN RoadMap at Country Level Three strategic priorities: 1-Mobilizing different organizations for effective joint action 2-Encouraging institutional coherence 3-Identifying and supporting nutrition leaders Three stages of country participation: 1-National authorities take stock of nutrition situation and of existing strategies, actors, programs 2-National plans for scaling up nutrition are developed 3-Rapid scale up of programs with domestic/external funding

20. Priority responses for Scaling Up Nutrition

21. Nutrition specific actions • Breastfeeding • Complementary feeding • Handwashing • Micronutrients for children: • Vitamin A, therapeutic Zinc, multiple micronutrient powders, plus deworming • Supplements for pregnant women: • Iron-folic acid, iodized oil • capsules (if needed) plus deworming • Fortification for general population: • Salt iodization, iron fortification • of staple foods 3 broad intervention groups • Treatment of severe acute malnutrition • Prevention/treatment of moderate • malnutrition

22. Incorporating nutrition considerations in other sectors GOVERNANCE GENDER Think Multi-Sectorally Act Sectorally Water & Sanitation Agriculture & Food Security Social Protection Environment & Climate Change Private Sector Poverty Reduction Trade/Fiscal Policies Health

23. Going to scale • Rapid expansion (explosion) is possible when the intervention requires no further staff, policies or substantive supplies, just building on and expanding what already exists (e.g. micronutrient interventions) • Linear expansion depicts a scenario where some added expense and maybe even policy change is needed (e.g. community based therapeutic feeding) • Exponential expansion is where considerable preparatory work needs to be done in human resources, infrastructure development, policy change, etc. (.e.g. community based behaviour change through GMP, conditional cash transfers) • For each of the ENI to be delivered through the “continuum of care” approach, each one of these scenarios has to be considered. Source Myers 1987

24. SUN RoadMap: Benchmarks for Country Engagement • Request goes from National Authorities to David Nabarro • In-country consultations underway via multi-stakeholder platform (the SUN group) and process • Nutrition policy in place and being pursued • Action Plan with Results Framework • Implementation with coordinated support from Government, in-country civil society and private sector, and Development Partners (World Bank, UN agencies and SCN, REACH, Intl NGOs)

25. Principles for support to SUN • The main investors in efforts to scale up nutrition are national governments themselves • Most countries affected by undernutrition will require external assistance to supplement their own expenditures. The level and pattern of support will vary from country to country • External funding for SUN should primarily come from existing donor programmes at national and global levels; Paris-Accra principles should insure harmonization and alignment at country level

26. Governance • Repeated experience across many decades confirms the importance of a high level oversight mechanism for generating the political support and guaranteeing the allocation of specific funds for nutrition activities (e.g. CONSEA in Brazil) • This is in addition to an intersectoral coordination mechanism which provides a clear division of responsibilities among implementing institutions. • In addition the ability to translate plans into action, including strengthening human capacity in designing and planning and implementing programmes for nutritional improvements, as well as creating mechanism for monitoring and evaluation, has to be created/strengthened.

27. FOUR PILLARS OF FOOD AND NUTRITION PLANS AND POLICIES HEALTHY LIFE STYLES NUTRITION SUSTAINABLE FOOD SECURITY FOODSAFETY For managing the “HOW” to do

28. Four Overarching Pillars of the Nutrition Policy Framework

29. Governance Approves plans and budgets HEALTHY LIFE STYLES NUTRITION SUSTAINABLE FOOD SECURITY FOODSAFETY Bringing it all together?

30. Governance • Government administrations are increasingly decentralized in many LMICs • A well-balanced comprehensive and cross-sectoral approach combining prevention and treatment, is difficult to achieve within a decentralized framework of government without: • adequate institutional arrangements (in particular cross-ministry coordination); • political leadership; • as well as guidance (human capacity) and incentives

31. Capacity Development • One of the weakest links limiting progress in nutrition security is the shortage of human resources in public health nutrition • Evaluation of UNICEF's support to growth monitoring revealed that growth monitoring programmes had not received sufficient funds to build local capacities. • The ADB/UNICEF RETA project in the 90s estimated that for taking to scale community-based nutrition programmes focussing on children under three years of age in Bangladesh, Cambodia, Pakistan, Sri Lanka and Viet Nam, some 3.6 million community members needed to be trained as mobilizers as well as some 180 thousand facilitators .

32. Capacity Development • Because in most LMICs the capacity to manage comprehensive multi-sectoral programmes for tackling the DBM is not there, a step-by-step approach is needed. • The first priority for developing plans to tackle the DBM in LMICs must be to tackle Maternal and Child Undernutrition. • Build as appropriate from the bottom up, i.e. Start with community based programmes for tackling in a few districts and progressively scale up as capacity is developed. • Over the medium and longer term need to consider how to tackle DBM, i.e. prevent and treat NCDs (obesity, diabetes, dyslipidaemia, etc.)

33. Capacity Development • It is increasingly recognized that training more graduates in nutrition will not in itself be enough to solve the capacity problem: alternate solutions are needed if “scaling up” is to be realized • Developing conceptual frameworks for defining public health nutrition practice, has been an essential part of establishing the curriculum needed in order to allow workforce development in Australia and elsewhere • All of this work confirms the need for three types of public health nutrition competence: • front line staff (most of whom are not nutritionists); • managers/supervisors (some of whom may be in health and others not); and • specialists of various types mostly at higher levels of the system.

34. Capacity Development • For each of these levels specific competencies need to be agreed and appropriate curricula to be developed. • Plans to strengthen capacity should consider “system”, “organizational” and “individual” level constraints. • The World Public Health Nutrition Association (WPHNA) aims to assist countries in defining these competencies and establishing the curriculum needed to train each of these sorts of staff. • This is part of the WPHNA objective of helping to establish systems to strengthen the professionalization of public health nutrition (wwww.wphna.org).

35. Monitoring and Evaluation

36. Conclusions • Efforts to tackle the DBM in LMICs should build on as appropriate the SUN movement for taking to scale proven nutrition actions for reducing MCU. • It is useful to specify that these nutrition actions will not only reduce MCU but also contribute to reducing the future DBM • Governance issues need treating with great care, in order not to create a bureaucratic straight jacket. (Think multisectorally and act sectorally) • In the mean time capacity needs to be built for managing multi-sectoralnutrition programmes, on a step by step basis, starting in Health. • Nutrition capacity development should consider individual, organizational and system level constraints (i.e. Think medium and long term) • Creation of capacity for monitoring and evaluating nutrition programmes should be prioritized