National Nutrition Investment Plan in the Republic of Uzbekistan

1. National Nutrition Investment Plan in the Republic of Uzbekistan D.I. Akhmedova,and I.F. Feynberg Ministry of Health of the Republic of Uzbekistan

2. Indicators of Nutrition Status conditioning Economic Losses • Anthropometric parameters • Wasting: weight, which doesn't match the height • Underweight: weight which doesn’t match the age • Low birth weight • Babies born with weight < 2500 grams • Micronutrient deficiency • Iron deficiency anemia (IDA) • Vitamin A deficiency (VAD) • Iodine deficiency disorders(IDD) • Folic acid deficiency (FAD) • Malnutrition among the child/ infant • Good practice for breastfeeding and complementary feeding

3. Change of prevalence rate for 7 nutrition indicators in Uzbekistan for the period of 1996-2006

4. Need for National Policy and Multi-sectoral Activity • Malnutrition is the consequence of inefficient multi-sectoral actions in providing of essential services to population; • Nutrition improvement will imply the interventions and actions of many sectors. • Nutrition is not the exclusive responsibility of MOH. • The Government as a whole is responsible for nutrition improvement. • Many ministries are responsible for implementation. • Nutrition improvement requires official National policy to mobilize multi–sectoral approach. • The key step forward is elaboration of the National Political Paper which should be submitted to the Cabinet of Ministers to issue official resolution.

5. In compliance with the instruction of the Cabinet of Ministers of the Republic of Uzbekistan of May 4, 2007, №07/103-175, the National Nutrition Investment Plan (NNIP) for the period of 2009-2011 was elaborated. • NNIP is a component of Welfare Improvement Strategy for the population of the Republic of Uzbekistan for the period of 2007-2011 and specifies the major goals, objectives and priorities for nutrition improvement using economic and organizational tools to reach the objectives.

6. NNIP Objective: Identifying the problems and the ways for their solutions • Comprehensive plan • Long – term and budget planning • Long – term national funding based on 3 year financial cycle • Implementation framework • Sustainability of current coverage • Scaling up of coverage • Integrated monitoring evaluation • New opportunity development • National policy and commitments • Responsibility for nutrition and health care • National nutrition goals and objectives

7. Process Governance Program Development Program Review Policy Action Normative Group 1 Food Strategy: Fortification Mandate from Social Sector Complex Commitment, Financing, Management Tools Legislative Group 2 Health Strategy: Supplementation Education Financial B/C Ratio Monitoring Coordination and management for NNIP development

8. % Comply FE/FA % Comply VAC % EBF % in GM % Adopt Change Output Output Output Output Output Output Output Output Output Activity Activity Activity Activity Activity Activity Activity Activity Activity Budget Budget Budget Budget Budget Budget Budget Budget Budget How NNIP Proposed Interventions Contribute to Achieving National Goals National Goals Synergy of Impact WG 1 Program Goals: Reduction % in IDA, NTDs, VMDs WG 2 Program Goals: Reduce % Stunting, IDA, VAD Program Objectives Program Objectives Pilot Defined Scale % USI % Consume FF Integrated Monitoring

9. NNIP components • Organizational, legislative and normative - legal framework for implementation and management of National Nutrition Investment Plan • Food based interventions • Providing essential nutrition services • Coordination and monitoring of National Nutrition Investment Plan implementation

10. Organizational, legislative and normative - legal framework for implementation and management of Nutrition Investment Plan • Transformation of National Alliance on Fortification (NAF) into National Alliance on Population Nutrition Improvement (NAN) • Establishment of Strategy Implementation Unit (SIU) on Population Nutrition Improvement and its activity • Elaboration of the drafts of legislative and normative – legal acts on nutrition improvement: - flour fortification; - salt iodization; - supplementation with micronutrients (iron, folic acid, Vitamin A); - fortificationof cotton oil with Vitamin A

11. Strategy Implementation Unit in Nutrition Improvement among the population Main functions: • Coordination of flour fortified and salt iodization; • Strengthening and scaling up the capacity of these components; • Consulting services, recommendations on the list of premix major users; • Tender for purchase of premix and production equipment; • Monitoring of production, quality and direct use of imported components; • Laboratory tests for certification of premix and other production materials; • Quality control and monitoring of imported and domestic flour; • Coordination of the program component on supplementation and education nutrition program development.

12. Food Fortification(flour fortification) • Increase in fortified flour consumption from 40% - during the first year up to80% - during the third year. • Within the framework of Nutrition Investment Plan a proposal on prolongation of validity period of Presidential Decree № ПП-153 «On the measures of implementation of the project “National Flour Fortification Program” is submittedto includeanew3-year program to scale up the coverage and achieve sustainability. • Program of flour fortification with iron, folic acid and other vitamins and minerals is scaled up to reach, at least, 80%of the population for sustainable anemia decrease in women by 20%,iron level increase at children of early ageby 10%,and decrease in congenital diseases by 50%.

13. Food fortification (salt iodization) • Scaling up of salt iodization program from the current level to sustainable population coverage of 85% • Decrease in IDD ~ by 51 % in 3 years

14. Fortification of cotton oil with Vitamin A • Elaboration of TOR for • Cotton Oil fortification with • Vitamin A Production and sales Of fortified oil Reducing under 5 mortality

15. Providing of essential nutrition services • Capacity building of health care system in providing of essential nutrition services • Procurement and distribution of supplements for target population groups • Copying and distribution of educational materials on nutrition for target groups • Providing the package of essential nutrition services • Community capacity development

16. Lactation Infancy Pregnant Pre Natal Weaning 6-24 months Young Child 24-60 months Integrated Delivery Model to Address Complex Puzzle of Malnutrition Life-Cycle-Based Model Program-Based Vertical Model E B F F E S U P L V I T A S U P L ED U C A T E

17. Essential Nutrition Services (ENS) Target Critical Life Cycle Segments Pregnancy Supplements: Iron Folic Acid Education: Prenatal care, Breastfeeding Delivery Education: Breastfeeding (BFHI) 0-6 months Child/Mother Supplements: Iron Folic Acid Education & Support: Breastfeeding 6-24 months Child/Mother Supplements: Iron Folic, Sprinkles, Vit A Education: Breast Feeding, Infant Feeding 24-60 months Child/Mother Supplements: Iron Folic, Vit A Education: Growth Monitoring School Girls Supplements: Iron Folic Education: Nutrition Education

18. Conceptual Model: 100+ Contacts over 69 MonthWindow of Opportunity National average 8 contacts/year with Public Health System WHO Regional Office for Europe Health for All database.

19. Development of Communication Capacity of the Community Interventions of Primary Health Care Unit at Makhalla Level • Interventions of primary health care unit should be strengthened to reach optimum efficiency • Home visits to high risk groups • Groups/services to support mothers and breastfeeding practice • Mobilization support for campaign drive • Partnership with makhalla facilitates policymaking, additional human and financial resources

20. MOH Policy, Financing, Management, Supply D R U G S M A T E R I A L M A N A G E T R A I N I N G M O N I T O R N O R M S ~ 4000 SVP, 580 HOSPITALS + OTHER PROVIDERS ~ 8,000,000 Mothers & Children Activities & Costs: Management & Logistics to Reach Point of Contact Integrated Management Info System

21. Coordination and monitoring of nutrition investment plan implementation

22. Nutrition & Economic Growth Model:The Virtuous Cycle Nutrition improves cognitive & physical growth to generate human capital. Increased human capital drives economic growth Economic Growth Improves Nutrition

23. Expected outcome for NNIP implementation • Established system of Control for financing and main NNIP activities implementation • Ensured micronutrient balance among risk groups. • Reduced rate of the clinical signs in malnutrition. • Increased physical and cognitive capacity of the future generation.

24. Expected outcome for NNIP implementation (cont)

25. Planning and budgeting for the main components of National Nutrition Investment Plan (NNIP)