National Nutrition Strategy and Action Plan (2021-2025)

NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NUTRITION PROGRAM DEPARTMENT OF PUBLIC HEALTH MINISTRY OF HEALTH ROYAL GOvERNMENT OF BHUTAN LEAD WRITERS / EDITORS Laigden Dzed, Deputy Chief Program Officer, Nutrition Program, Ministry of Health Hari Prasad Pokhrel, Senior Program Officer, Nutrition Program, Ministry of Health PUbLIShED bY Nutrition Program Department of Public Health Ministry of Health Thimphu Bhutan Copyright ©2021 Nutrition Program, Ministry of Health Bhutan SUGGESTED CITATION National Nutrition Strategy and Action Plan 2021-2025, Nutrition Program, Ministry of Health, Bhutan:2021. NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NUTRITION PROGRAM DEPARTMENT OF PUBLIC HEALTH MINISTRY OF HEALTH ROYAL GOvERNMENT OF BHUTAN NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 3 “As a country, we must continue to focus on the pursuit of higher standards. Whatever we do, we have to strive for excellence. As I always say, good is not good enough.” - His Majesty’s address at the 11th Royal University of Bhutan Convocation, 8th June 2016. i | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) FOREWORD Food and nutrition security worldwide is recognized as a human right and a critical ingredient for economic, social and human development. The causes of recent food crises and the proposed responses show the complexity of the global food system and highlight the growing importance of factors that go beyond agriculture and the household level. Yet, interventions to address food insecurity have often focused on agriculture-based approaches and have been geared towards improving the households’ access to food. As a result, progress reports show that the developing world is particularly off-track in achieving the goals closely linked to food and nutrition security (FNS). In line with the ‘Food Security and Nutrition Policy’ (2014), and to achieve the goals of 12 FYP and other global commitments, the Ministry of Health has developed and adopted the National Nutrition Strategy and Action Plan (2021-2025). It aims to identify the various challenges of malnutrition and positions a strategic plan of action to tackle these at an appropriate time when the world is gearing towards achieving Sustainable Development Goals on food security and improving nutrition. Bhutan has witnessed improvement in the child growth indicators but high rates of undernutrition, particularly stunting and micronutrient deficiencies among vulnerable populations still persists which is of grave concern for us. The need to address the immediate and underlying causes of under nutrition especially among children, adolescent girls and women remains a top priority for the overall improvement of the social and economic conditions of our people. The multidimensional aspects of malnutrition have been viewed carefully during the development of this document in recognition of the direct and indirect roles played by other sectors and agencies. If food and nutrition security of the country is to be improved, a cross-sectoral approach has to be adopted. Improving food and nutrition security of the country is not only central for achievement of the Sustainable Development Goals but also for the development of the country. With this strategy, we take a crucial step towards ensuring food and nutrition security for our people, so that they would be able to contribute to the social and economic development of the country. Dr Pandup Tshering SECRETARY, MoH NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | ii TABLE OF CONTENTS FOREWORD i List of Abbreviations iii EXECUTIVE SUMMARY vi CHAPTER 1: INTRODUCTION 1 Background 3 Cross-sectoral collaboration 3 CHAPTER 2: ANALYSIS OF THE CURRENT SITUATION 8 Triple burden of malnutrition 9 Child undernutrition 9 Anemia 10 Micronutrient Deficiencies 11 Overweight and obesity 13 CHAPTER 3: RATIONALE, VISION, MISSION & TARGETS 20 Rationale 21 Vision 23 Mission 23 Guiding Principles 25 CHAPTER 4: OBJECTIVES 28 Results Framework 31 CHAPTER 5: GOVERNANCE 36 Governance and implementation modality for NNSAP 37 National Nutrition Task Force (NNTF) 37 CHAPTER 6: STRATEGIC RESULT AREAS 42 Strategic Result Area 1: Special focus on 1000 golden years 43 Strategic Result Area 2: Focus on school aged children 44 Strategic Result Area 3: Focus on women of reproductive age 47 Strategic Result Area 4: Healthy diets for general population 48 Strategic Result Area 5: WASH, food and nutrition security 50 Strategic Result Area 6: Clinical nutrition and dietetics 52 Strategic Result Area 7: Governance and partnerships 53 Strategic Result Area 8: Monitoring and evaluation 54 ACTION PLANS 55 iii | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) LIST OF ABBREvIATIONS AES Annual Education Statistics AFHS Adolescent Friendly Health Services AHP Adolescent Health Program ANC Antenatal Care APD Agriculture Production Division BAFRA Bhutan Agriculture and Food Regulatory Authority BHU Basic Health Unit BMIS Bhutan Multiple Indicator Survey C4CD Care for Child Development CF Complementary Feeding CHP Child Health Program CMO Chief Medical Officer CPO Chief Program Officer CVD Cardiovascular disease DAMC Department of Agricultural Marketing & Co-operatives DDM Department of Disaster Management DHO District Health Officer DHS District Health Services DMS Department of Medical Services DoA Department of Agriculture DoL Department of Livestock DoPH Department of Public Health DoT Department of Trade EmONC Emergency Obstetric and Newborn Care EMSD Emergency Medical Services Division FCBL Food Corporation of Bhutan Limited FCS Food Consumption Score FNPH Faculty of Nursing and Public Health FNS Food and Nutrition Security FYP Five Year Plan GNHC Gross National Happiness Commission HAZ Height for Age z-Score HPD Health Promotion Division ICT Information and Communication Technology IDD Iodine Deficiency Disorder IMNCI Integrated Management of Childhood Illness IYCF Infant and Young Child Feeding KAP Knowledge, Attitude and Practice KPI Key Performance Indicator LG Local Government LSRD Lifestyle Related Disease NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | iv MAM Moderate Acute Malnutrition MBFHI Mother and Baby Friendly Health Facility Initiative MCH Maternal and Child Health MNT Medical Nutrition Therapy MoAF Ministry of Agriculture and Forest MoEA Ministry of Economic Affairs MoE Ministry of Education MoH Ministry of Health MoHCA Ministry of Home and Cultural Affair MoWHS Ministry of Works and Human Settlement NCD Non-Communicable Disease NCDD Non-Communicable Disease Division NGO Non-Governmental Organization NKRA National Key Result Area NNSAP National Nutrition Strategy and Action Plan NNS National Nutrition Survey NNTF National Nutrition Task Force NP Nutrition Program NRU Nutrition Rehabilitation Unit PAR Poverty Analysis Report PEN Package of Essential Non-Communicable Disease PNC Postnatal Care PN Peripheral Neuropathy RCDC Royal Centre for Disease Control RGoB Royal Government of Bhutan RH Reproductive Health RMNHP Reproductive, Maternal and Newborn Health Programme SABER System Approach for Better Education Results SAM Severe Acute Malnutrition SAP School Agriculture Program SBCC Social Behavior Change Communication SHND School Health and Nutrition Division UNICEF United Nations Children’s Fund VAD Vitamin A Deficiency VAR Variety Release Committee WASH Water Sanitation and Hygiene WB World Bank WFP World Food Program WHO World Health Organization WSFS World Submit on Food Security vi | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) EXECUTIvE SUMMARY Overview The results from the National Nutrition Survey 2015 show that the child stunting prevalence still stands at 21.2%. Although stunting has dropped from 33.5% in 2010, regional disparities remain persistently elevated with 29.1% prevalence rate in the eastern region followed by 18.5% and 16.2% in the central and western regions respectively. Investing in nutrition is also recognized as crucial for the fulfillment of the fundamental rights- especially of the most vulnerable children, girls and women. The National Nutrition Strategy and Action Plan (NNSAP) aims to translate the national policies into a clear guiding document that will facilitate the operational planning, implementation, monitoring and resource mobilization to address the many underlying and direct causes of malnutrition in Bhutan. The development process of the NNSAP was driven by the Nutrition Program of the Ministry of Health, and was widely consultative, involving all key nutrition stakeholders through the multisectoral process that was open, inclusive and built on existing and emerging alliances, institutions and initiatives. The process of the development ensured that the plan is evidence-informed and recognized successes while also taking care to create a result- based appraoch which provides a common results and accountability framework for monitoring and evaluation. Objectives The main objective of the NNSAP is to improve nutritional security, especially for those at higher risk of malnutrition such as children, women, adolescents, the elderly and people with special needs in collaboration with multiple sectors to achieve the national and global targets for malnutrition across all age groups by 2025. Implementation For the implementation of NNSAP, Nutrition Program, MoH will lead the coordination between all relevant sectors. The NNSAP is to be incorporated in the plans of all the relevant stakeholders - Annual Work Plans (AWPs) and Annual Performance Agreement (APA) or equivalent. Nutrition Program, Department of Public Health (DoPH) will be responsible for coordination and management of NNSAP at the national level. The program will also NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | vii advocate and encourage the districts and other relevant stakeholders to plan and take up planning and implementation of the NNSAP through the multisectoral National Nutrition Task Force (NNTF) committee. Strategic Result Areas The nutrition agenda for next five years is shaped along the following strategies across life cycle and their subsequent implementation of interventions in the priorities by all relevant stakeholders. 1. To improve the nutritional status of infants and young children (preschool age) with special focus on 1000 golden days • Promote, protect and support breastfeeding for children: early initiation of breastfeeding, exclusive breastfeeding for the first six months of baby’s life and continued breastfeeding for at least two years • Promote optimal complementary feeding with a special focus to improve the dietary diversity from locally available foods • Provide appropriate micronutrient supplements to children under five years • Strengthen growth monitoring and promotion for children under five years of age • Strengthen the screening and management of acute malnutrition, low birth weight infants and improve referral mechanism and linkage between the health facilities • Strengthen the screening and management of child development including prevention and early management of childhood illnesses • Improve advocacy and encourage community engagement to achieve optimal child nutritional status 1. To improve the nutritional status of school aged-children including monastic institutions through improved knowledge, skills and practices • Optimize school meals using Plus School Menu, incorporation of food fortification and strengthen linkages to local farmers, to ensure nutritional requirements of school-aged children are met 1 2 viii | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) • Develop and implement a comprehensive Social Behavior Communication Change (SBCC) Strategy to improve dietary and health practices for school aged children and their parents/communities • Improving school kitchen and store infrastructure and facilities in place for schools to be able to provide nutritious and safe school meals • Strengthening online, digital, monitoring and reporting systems for school health and nutrition program to enable better programming and decision-making • Capacity building of relevant staff on an integrated approach of managing school feeding and nutrition program including food preparation, storage, food safety and WASH • Provide recommended micronutrient supplements to school aged children • Strengthening the healthy food environments in schools and monastic institutions to manage and control the marketing of unhealthy foods and beverages • Implement the required physical activity recommendations including sports as part of school curriculum 1. To improve the nutritional status of adolescents, youth, women of reproductive age, pregnant and lactating mothers • Improving and strengthening the coverage of recommended 8 ANC visits, 4 PNC, and early booking for the pregnant women and provision of nutrition services at each visit in line with the WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience • Improving the counselling services on nutritious and safe diets, physical activity, rest and weight gain • Promoting, strengthening and supporting the supply and consumption of multiple micronutrients including Iron Folic Acid tablets, Vitamins and calcium lactate for pregnant women • Strengthening the management and screening of anemia for adolescent girls, and women in the reproductive age group 3 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | ix • Strengthening and expanding the implementation of package of preconception nutritional care • Strengthening and expanding Adolescent Friendly Health Services to deliver nutrition services • Improving advocacy to promote healthy dietary practices among adolescents • Reducing micro-nutrient deficiency status among the adolescents 1. To improve the nutritional status of the general population by promotion of healthy diets and physical activity to prevent overweight, obesity and non-communicable diseases • Implementing a comprehensive strategy and guideline for prevention, management and control of diet related NCDs • Improve capacity of service providers on prevention, management and control of diet related NCDs through capacity building as well as ensuring a steady supply chain of necessary equipment • Creating awareness for both the general public as well as policy makers on the importance of prevention, management and control of diet related NCDs • Involving community leaders in the prevention and control of NCDs • Ensuring consumer rights to access good quality and appropriate foods in line with the provisions of the consumer protection act • Ensuring trade and marketing policies are geared towards providing healthy and nutritious foods • Ensuring consumers’ right to information through labelling of foods 1. To strengthen food and nutrition security, water sanitation and hygiene as nutrition sensitive interventions • Improve the availability of – physical and economic access to – and the consumption of diversified food commodities (cereals, legumes) and fruits and vegetables through enhanced production 4 5 x | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) • Improve the availability of – physical and economic access to – and the consumption of diversified animal proteins • Promote food diversification and fortification • Ensuring food safety at all levels • Increase access to safe drinking water • Increase access to safe and sustainable improved sanitation services • Improve hygiene behavior practices and their management 1. To improve and scale-up services and practices related to clinical nutrition and dietetics • Improve the hospital food service system • Standardize the implementation of Medical Nutrition Therapy (MNT) including enteral and parenteral nutrition • Advocating and familiarizing health staff on clinical nutrition • Participation in the community nutrition initiatives. • Promoting continued professional development and improving coordination among nutrition professionals 1. Strengthening governance and multi-sectoral partnerships in support of nutrition interventions and have resilient systems for nutrition in emergency preparedness • Establishing a platform for multi-sectoral coordination for implementing and strategizing nutrition interventions across all sectors and levels • Identifying and empowering all relevant sectors to buy-in the nutrition agenda • Conducting regular planning and review meetings to align the annual nutrition planning process in alignment with nutrition action plan • Advocacy for partnerships and resource mobilization • Strengthen preparedness for nutrition in emergency situations 6 7 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | xi 1. To improve monitoring and evaluation of nutrition security situations and related interventions • Strengthen feedback mechanisms on nutrition information among nutrition stakeholders • Strengthen and mainstream nutrition information system with DHIS 2 platform • Conduct periodic nutrition surveys and need-based assessment/ research to inform policy, program design and implementation 8 1 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 2 CHAPTER 1: INTRODUCTION 3 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) BACkGROUND The National Nutrition Strategy and Action Plan (NNSAP), 2021-2025, is underpinned from the policy directives reflected in the National Food and Nutrition Security Policy of the Kingdom of Bhutan (FNS) 2014, The National Health Policy 2011 and the 12th Five Year Plans (2019-2023). These National Policies and Strategies, in one form or the other, have components that place importance on the improvement of the nutrition status of Bhutanese population, through multisectoral action, while also recognizing investments for nutrition as a critical development imperative. The NNSAP is meant to translate the national policies into a clear guiding document that will facilitate the operational planning, implementation, monitoring and resource mobilization to address the many underlying and direct causes of malnutrition in Bhutan Investing in nutrition is also recognized as crucial for the fulfillment of the fundamental rights- especially of the most vulnerable children, girls and women. It constitutes the foundation for human development, by reducing susceptibility to infections, related morbidity, disability and mortality burden, enhancing cognitive ability, cumulative lifelong learning capacities and adult productivity. Nutrition is acknowledged as one of the most effective entry points for human development, poverty reduction and economic development, with high economic returns. The NNSAP is meant to translate the national policies into a clear guiding document that will facilitate the operational planning, implementation, monitoring and resource mobilization to address the many underlying and direct causes of malnutrition in Bhutan, taking into account the goals set for the 12th Five Year Plans (2019-2023), and commitment to the Global Nutrition Targets endorsed by the sixty fifth World Health Assembly resolution WHA65.6, as well as Bhutan’s continued commitment to the Sustainable Development Goals (SDGs). CROSS-SECTORAL COLLABORATION The NNSAP acknowledges that improving the nutrition status of the Bhutanese population requires cross-sectoral initiatives, taking into account the many faceted dimensions of the issue prevalent in the country. NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 4 The key sectors contributing to ensure good nutritional status in Bhutan are identified as Ministry of Health (MoH), Ministry of Agriculture and Forest (MoAF), Ministry of Education (MoE), and various supporting sectors such as Ministry of Economic Affairs (MoEA), Dratshang Lhentshog, other monastic institutions, academic institutions, Ministry of Works and Human Settlement (MoWHS), Non- Governmental Organizations (NGOs), Civil Society Organizations (CSO), community groups, Youth and Adolescents Development agency and Local Governments (LGs). The MoH has responsibility to identify the nutritional problems in each group, throughout the life cycle, and to help identify the respective roles of various sectors in achieving nutrition and food security and safety. CROSS-SECTORAL COLLABORATION MoH Nutrition-specific interventions to prevent and treat malnutrition MoAF Avalaibility and accessibility to affordable, nutritious and safe foods MoE Build nutrition literacy and life- skills, deliver micronutrient supplements OTHER SECTORS (NGOs, LG, DPs) Adoption of sector relevant nutrition programming Figure 1: Cross Sectoral Collaboration 5 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) The MoAF has responsibility to ensure food security in the country, in particular with regard to three pillars of food security: food availability, accessibility and stability (WSFS 2009). The Bhutan Agriculture and Food Regulatory Authority (BAFRA) has an important role in ensuring food safety & quality standards for the population of Bhutan. The MoE has a special role and responsibility of collaborating with the MoH and MoAF to translate the findings of the nutrition and food security situational analysis into recommendations for improved knowledge, skills, better learning outcome and practices of school children and pre-school children, thus playing a key role in ensuring good health and nutrition in the young, as well as for the future generations. The role of social sectors—primarily health, education and agriculture—is critical for the prevention and treatment of nutritional deficiencies. The MoH has a special responsibility with regard to food utilization, since nutrition security is achieved for a household when secure access to food is coupled with a sanitary environment, adequate health services, and adequate care to ensure a healthy life for all household members. The role of the MoEA is to improve the distribution system and the accessibility of food in the country. It plays a major role in the distribution of healthy food, making them accessible and affordable for everyone, especially foods produced in Bhutan. The Department of Trade (DoT) of MoEA can contribute to achieve this through price controls, reduce and monitor the import of foods high in salt, fat, sugar, and of soft drinks, presence of harmful foods, or harmful substances in food, at the wholesale and retail level. NGOs, monastic bodies, CSOs and others can all contribute to health promotion, communication and community mobilization for quality nutrition behavioral practices. Local governments and communities have an equally important role. Improving the nutrition status of the Bhutanese population requires cross- sectoral initiatives, taking into account the many faceted dimensions of the issue prevalent in the country NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 6 7 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 8 CHAPTER 2: ANALYSIS OF THE CURRENT SITUATION 9 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) TRIPLE BURDEN OF MALNUTRITION Triple burden of malnutrition refers to the coexistence of over nutrition, undernutrition and micronutrient deficiencies. Over nutrition, undernutrition, and micronutrient deficiencies equally increase the risk of various health problems. Child undernutrition increases the risk of childhood mortality and poor cognitive development, and overnutrition is associated with increased risk of various non-communicable diseases such as high blood glucose levels, raised blood pressure, abdominal obesity and high lipid profiles. Overweight/obesity during pregnancy is linked with several adverse maternal and fetal consequences during pregnancy, delivery and the postpartum period. CHILD UNDERNUTRITION The results from the National Nutrition Survey 2015 show that the child stunting prevalence still stands at 21.2%. Although stunting has dropped from 33.5% in 2010, regional disparities remain persistently elevated with 29.1% prevalence rate in the eastern region followed by 18.5% and 16.2% in the central and western region respectively1. The prevalence of acute malnutrition (wasting) stands at 4.3% at the national level with the highest rates of acute malnutrition being found in the poorest section (7%) in the society. Severe wasting (SAM- Severe acute malnutrition2) is > 1 percent in all wealth quintiles except Q5 (Q1 4.3 percent, Q2 1.8 percent, Q3 1.2 percent and Q4 2.6 percent), which is of severe public health significance as per WHO standards. Children with SAM have nine-times higher risk of death than their normal counterparts. 1 National Nutrition Survey 2015 2 Weight for height <-3 standard deviation as per WHO reference standards. UNDER NUTRITION MICRONUTRIENT DEFICIENCIES OvER NUTRITION Figure 2: Triple Burden of Malnutrition NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 10 ANEMIA Anemia in Bhutan is a significant public health problem. The National Nutrition Survey 2015 shows that 43.8% of children (6-59 months), 31.3% of adolescent girls (10-19 years), 34.9% of non-pregnant women (15-49 years) and 27.3% of pregnant women are anemic. These findings demonstrate that anemia is a lifecycle problem, and to correct anemia in children, anemia in women must be corrected before they become pregnant, maintaining good iron levels throughout pregnancy and lactation. However, Bhutan has also made significant reductions in the anemia prevalence over the past 12 years. Since the national anemia study in 2003, prevalence of anemia among children less than five years of age has reduced by half of 2003 level. Similarly, anemia prevalence among non-pregnant women has reduced by over a third of its 2003 levels. Figure 3: Stunting, Wasting and Underweight status in children under five National Nutrition Survey 2015 1 21.2% 9.0% 11.1% 7.7% 7.6% 5.6% 12.4% 5.4% 3.2% 4.2% 4.0% 4.6% 4.3% 16.2% 18.5% 29.1% 16.0% 26.1% 2 3 4 5 6 Stunting Wasting Underweight Figure 4: Anemia trends National Nutrition Survey 2015 80.6% 54.8% 51.5% 2005 National anemia study 2003 Child (6 to 59 months or age) Non-pregnant women NNS 20152007 2009 2011 2013 48.2% 44.9% 41.5% 38.2% 34.9% 74.5% 68.3% 62.2% 56.1% 50.0% 43.8% National Western Region Central Region Eastern Region Urban Areas Rural Areas 11 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) MICRONUTRIENT DEFICIENCIES There is limited biochemical and dietary information on micronutrient status in Bhutan suggesting a need to conduct a micronutrient survey, including biochemical, dietary and clinical components. The generally poor dietary diversity prevalent among the Bhutanese households as indicated in the NNS 2015, can be indicative of the The generally poor dietary diversity prevalent among the Bhutanese households as indicated in the NNS 2015, can be indicative of the inadequacy of the intake many micronutrients inadequate intake of many micronutrients such as B vitamins, but also of iron, folate, vitamin A and possibly other key nutrients, such as zinc, found especially in fresh foods. A national micronutrient survey is needed to understand the extent of the micronutrient deficiencies in Bhutan. IODINE DEFICIENCY DISORDER (IDD) vITAMIN A DEFICIENCY (vAD) vITAMIN B DEFICIENCIES In 1983 IDD was a national public health problem in Bhutan and IDD control program was initiated by MoH 1998 and 2012 Peripheral neuropathy (PN) outbreaks observed in schools and B vitamin defficiency was suspected In 1984, the prevalance of VAD among pre- school children was 14%. Control program was initiated In 2003 IDD was eliminated from Bhutan and a followup study in 2010 indicated the IDD elimination was sustained MOH, in 2014, found a high prevalence of thiamine and cobalamin deficiency in school children In 1999, VAD was found to be absent among pregnant women and children. Supplementation program was continued In 2015 the household iodised salt coverage was 99% but there is a need for periodic surveys on iodine status, and regular monitoring of iodine in salt. NNS 2015 also shows inadequate animal sourced proteins, fruits and vegetables in the diets of Bhutanese Vitamin A supplementation given to women and children. There is a need for study to acertain the status of VAD 21% OF CHILDREN UNDER FIvE ARE STUNTED 44% CHILDREN UNDER 5 ARE ANEMIC 33.5% ARE OvERWEIGHT AND 11.4% OF OBESE (BHUTANESE AGED 15-69 YEARS) Figure 5: Micronutrient Deficiencies NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 12 13 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) OvERWEIGHT AND OBESITY The NCD STEP Survey 2019 which collected the data for Bhutanese aged 15-69 shows: 33.5% are overweight and 11.4% are obese compared to 27% men and 40% women were overweight in 2014; 87% do not consume sufficient fruits and vegetables; 17% engaging in heavy episodic drinking; 7% did not meet the WHO recommended physical activity of 150 minutes of moderate intensity physical activity per week; 18% having high blood pressure, and 1.9% of the population having raised blood sugar. Based on the available data, NCDs cause the highest proportion of deaths for all age groups accounting for 71% of all deaths3. This makes NCDs Bhutan’s biggest health challenge. The NNSAP will coordinate closely with related strategies and plans to ensure best outcomes and optimize the use of resources, with greater focus on interventions targeted to vulnerable populations in the context of a life cycle approach for disease prevention and control. 3 Annual Health Bulletin, Ministry of Health, 2020. Figure 6: Overweigh and Obesity as reported by the Non-Communicable Diseases STEPS survey 2019 Normal Weight Underweight Overweight Obese 0% ༡༡10% 15-24 years years years years 25-39 40.54 55-69 20% 30% 40% 50% 60% 70% 80% 90% 100% 4.6 13.4 15.9 11.8 38.8 2.9 46.6 42.2 1.6 40.3 38.5 46.2 1.9 16.4 6.1 72.9 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 14 15 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) THE TRIPLE BURDEN OF MALNUTRITION THROUGH THE LIFE CYCLE AND ACROSS GENERATIONS AND SHARED DRIvERS The causes of malnutrition are directly related to inadequate dietary intake and diseases. However, household food security, health status, maternal and child care services, environmental factors and others contribute indirectly. While most nutrition interventions are delivered through the health sector, non-health interventions are also critical. Actions should target the different causes to reach sustainable change, which require multi-sectoral approaches. It is imperative that nutritional disparities and the triple burden of malnutrition must be considered from a life course perspective. This is because there is evidence that shows the intergenerational transmissibility of malnutrition. For example, women of childbearing age living in socioeconomically deprived circumstances have documented the intergenerational transmission of both stunting and obesity. Similarly, paternal excessive body weight has also been associated with increased obesity risk in children. The triple burden of malnutrition through the life cycle and across generations and shared drivers presented in Figure 7. NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 16 Fi gu re 7 : D riv er s of M al nu tr iti on ba by PR EC ON CE PT IO N PR EG NA NC Y PO ST PA RT UM OV ER W OB ES UN DE R SO CI AL A ND DE MO GR AP HI C Li fe st yl e an d ha bi ts Ps yc ho lo gi ca l f ac to rs So ci oe co no m ic d is ad va nt ag e & p ov er ty Fo od in se cu ri ty Lo w b ir th w ei gh t, pr em at ur e bi rt h, m at er na l un de rn ut ri tio n. Hi gh b ir th w ei gh t, pr em at ur e bi rt h, m at er na l o ve rw ei gh t. BE HA VI OR AL Dr iv er s o f t he do ub le b ur de n of m al nu tr iti on a cr os s th e lif e co ur se M at er na l o be si ty , e xc es s w ei gh t g ai n, g es ta tio na l di ab et es , e pi ge ne tic ch an ge s, p os tp ar tu m w ei gh t r et en tio n. Lo w w ei gh t g ai n, in ad eq ua te fo od in ta ke , p oo r a pp et ite or lo ss o f a pp et ite , f oo d in se cu ri ty , i na de qu at e fe ta l nu tr iti on . ba by PR EC ON CE PT IO N PR EG NA NC Y PO ST PA RT UM OV ER W OB ES UN DE R SO CI AL A ND DE MO GR AP HI C Li fe st yl e an d ha bi ts Ps yc ho lo gi ca l f ac to rs So ci oe co no m ic d is ad va nt ag e & p ov er ty Fo od in se cu ri ty Lo w b ir th w ei gh t, pr em at ur e bi rt h, m at er na l un de rn ut ri tio n. Hi gh b ir th w ei gh t, pr em at ur e bi rt h, m at er na l o ve rw ei gh t. BE HA VI OR AL Dr iv er s o f t he do ub le b ur de n of m al nu tr iti on a cr os s th e lif e co ur se M at er na l o be si ty , e xc es s w ei gh t g ai n, g es ta tio na l di ab et es , e pi ge ne tic ch an ge s, p os tp ar tu m w ei gh t r et en tio n. Lo w w ei gh t g ai n, in ad eq ua te fo od in ta ke , p oo r a pp et ite or lo ss o f a pp et ite , f oo d in se cu ri ty , i na de qu at e fe ta l nu tr iti on . ad ul t ch il d ad ol es ce nt BI OL OG IC AL In he ri ta bi lit y Ep ig en et ic s Ea rly li fe e xp er ie nc e Co nt in ue d ex ce ss w ei gh t ga in , u nh ea lth y di et , l ow ph ys ic al a ct iv ity , o be si ty & re la te d he al th p ro bl em s. Lo w -p ai d, re pe tit iv e jo bs w ith in fl e xi bl e op po rt un iti es fo r ph ys ic al a ct iv ity , l es s en co ur - ag em en t a nd s oc ia l s up po rt . Ra pi d ca tc h- up g ro w th , n o br ea st fe ed in g, le ss e xp os ur e to h ea lth y fo od s an d fl a vo rs , fo od in se cu ri ty , s tu nt in g. Re du ce d ca pa ci ty fo r ph ys ic al la bo r. Re du ce d ca pa ci ty fo r ph ys ic al la bo r, lo w er e du ca - tio na l a tt ai nm en t, re st ri ct ed ec on om ic p ot en tia l. Fo od s up pl y an d sy st em s Fo od p or ti on s iz es a nd c os t Cu ltu ra l a nd s oc ia l a sp ec ts U rb an a nd b ui lt en vi ro nm en t Tr ad e an d tr ad e po lic ie s EN VI RO NM EN TA L Un tim el y or in ad eq ua te fe ed in g; fr eq ue nt in fe ct io ns ; in ad eq ua te fo od , h ea lth an d ca re . EI GH T IT Y W EI GH T Th is in fo gr ap hi c is th e pr op er ty o f S ig ht a nd L ife : w w w .s ig ht an dl ife .o rg | De si gn b y S1 G ra fi k D es ig n: w w w .s 1- bu er o. co m 17 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) • 8% (WFP FCS index) of households in Bhutan have a poor or borderline diet– diets that do not contain balanced food intake that is sufficiently diverse and nutritious food (NNS 2015) • Only around 77% newborn have best start of life that is colostrum feeding and initiation of breastfeeding in first hour of birth and 51% of the children were exclusively breastfed (NNS 2015) • Only 11.7% of children are fed with minimum acceptable diet, 16.6% given iron rich food and 15.3% provided with 4 or more food groups (NNS 2015) • Thiamin deficiency among school children 90.13% during mid-academic year and cobalamin deficiency of 64.7% detected in school children from 7 districts4. • Diarrheal diseases affect 25% of under-5 children (BMIS, 2011). • Nationally more than 4 in 10 children under five are anemic and 3 in 10 adolescent girls are anemic. • 40% of student’s drink carbonated drink and 32.2% students eating fast food (School based health survey 2016) • 87% respondents have insufficient fruits and vegetables (STEP survey 2019) • Nationally 2.2% of households faced food insecurity while dietary diversity in households are very poor (NNS 2015). • Food shortages and chronic food insecurity are greater in the rural areas (PAR, 2017), where poverty is also higher. • Only 52% reported starting ANC visits in the first trimester, and only 17.7% of women in the eastern region received Bhutan’s recommended 8 ANC visits (NNS, 2015). • 16% of the pregnant women reported consuming alcohol, and 42%consumed betel nut (NNS, 2015). • Almost 40 percent of rural households still uses pit toilets which are as lethal as open defecation which can lead to diseases contributing to malnutrition. • Also, there are inadequate WASH facilities in Health Care Units which makes hospital environments unsafe for the patients, health staff and attendants. • Rapid urbanization (37% so far, with an additional 3.7% change each year (World Bank, 2012) affects Bhutan’s agricultural productivity as young people leave the countryside to find education or jobs in the cities (Maetz, 2012). • There is gender parity through secondary school, however in tertiary education the ratio of girls to boys is only 0.79 (AES 2015). The adult literacy rate for females is 45.2% compared to 66% for males. 60% of males have attended or previously attended school in comparison to only 48% of females (BLSS 2012). • In the richest quintile, 94% used improved sanitation, versus 31.6% of the poorest; 8.2% of the poorest used unimproved drinking water versus 0.2% of the wealthiest. Where the head of household had no education, 42% of households used an unimproved sanitation facility versus 5.8% of those with secondary or higher education (BMIS 2010). 4 Prevalence of Thiamine and Cobalamin deficiency in boarding school children from seven districts of Bhutan with history of Peripheral Neuropathy outbreaks. Nutrition Program, Ministry of Health, 2014. NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 18 19 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 20 CHAPTER 3: RATIONALE, VISION, MISSION & GUIDING PRINCIPLES 21 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) DEvELOPMENT PROCESS The development process of the NNSAP was driven by the Nutrition Program of the Ministry of Health, and was widely consultative, involving all key nutrition stakeholders through the multisectoral process that was open, inclusive and built on existing and emerging alliances, institutions and initiatives. At the national level all relevant key stakeholders and development partners - both from the country office as well as from regional offices were involved. Consultative workshops with the relevant field workers were conducted and the document was shared with all relevant officials including the District Health Officers, Chief Medical Offices and other field workers for comments and feedback. The process of the development ensured that the plan is evidence-informed and recognized successes while also taking care to create a result-based system which provides common results and accountability framework for monitoring and evaluation. RATIONALE The National Nutrition Survey 2015, shows that chronic malnutrition in children under five is still a public health concern. Anemia prevalence despite the significant decline in the last twelve years, still remains a public health problem for children under five, pregnant women, adolescent girls and women of reproductive age. Even though the survey indicates the percentage of households suffering from food insecurity is very low, household dietary diversity is very poor in the country. The high burden of all forms of malnutrition in Bhutan warrants appropriate national level interventions. Nutrition is identified as one of the key national priorities in the 12th Five Year Plans (2019-2023). The National Key Result Area (NKRA) 8 is about ensuring food and nutrition security, a key contribution from the health sector is to ensure the improvement of the nutrition status of the general population. Key performance indicators for NKRA 8 have already been linked to achieving the global nutrition commitments. The NNSAP is meant to guide the operational planning, implementation, monitoring and resource mobilization for achieving the targets set in the 12 FYP and beyond. NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 22 23 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) A nation free from all forms of malnutrition where all her people achieve optimal health, nutrition and wellbeing. The key strategic elements reflected in this vision are; • A nation: where the NNSAP strives to impact the whole of the country • All forms of malnutrition: where there is a need to address the triple burden of malnutrition as well as diet-related non-communicable diseases • All (her) people: a life-course approach is essential, including all population groups i.e., infants, children, adolescents, mothers, the general population • Health and wellbeing: NNSAP will take into consideration the wider definition of health adopted by WHO, where the health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” This vision is also aligned with the Royal Governments of Bhutan’s development philosophy of Gross National Happiness. To implement evidence-informed nutrition interventions and work with relevant agencies and partners to ensure universal access to effective nutrition actions and to healthy and sustainable diversified diets. To do this NNSAP will; • Set, align and advocate for priority actions to improve nutrition; • Develop evidence-informed guidance based on robust scientific and ethical frameworks; • Support the adoption of guidance and implementation of effective actions; • Monitor and evaluate policy and program implementation and nutrition outcomes. vISION MISSION NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 24 25 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) The key elements of the mission statements are: • Implementing evidence-informed nutrition interventions: evidence-informed guidance developed through robust scientific and ethical framework free from conflict of interest, must underline the development of effective and efficient nutrition-specific and nutrition-sensitive solutions; • Working with relevant agencies and partners: NNSAP will help set, align and advocate for priorities to move the nutrition agenda to achieve the goals and targets set for the year 2023 and 2025; • Healthy and Sustainable diets: the fundamental role of healthy diets at all stages of life, as well as the importance of sustainable environments and food systems in achieving the nutrition targets are recognized. GUIDING PRINCIPLES NNSAP Intersectoral participatory approach Inclusiveness Life-course approach Evidence- informed policies and practices Alignment to the 12 FYP and Global Targets NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 26 The NNSAP is guided by the following principles: Intersectoral participatory approach Multi-sector collaboration for developing effective interventions to address the triple burden of malnutrition; it requires commitment and actions by various sectors (agriculture, health, education as key sectors, and trade, social support, media as supporting sectors) to ensure supportive policy coherence. It requires meaningful community participation and engagement, as well as active partnerships among national authorities, civil society organizations, academia and the private sector –free from conflicts of interest. The National Nutrition Strategy is evidence and rights based, equity focused, gender responsive and system centered. Life-course approach A life-course approach starts with maternal health. Integral components of a life-course approach include preconception care, antenatal and post natal care, early initiation of breastfeeding, promotion of breastfeeding; appropriate infant and young child feeding practices; a healthy lifestyle for children, adolescents and youth; a healthy working life; healthy ageing; and care of people in later life. Evidence-informed policies and practices Evidence-informed guidance for nutrition interventions should be considered, where available. Country-specific research is needed to identify the common causal pathways of the double burden of malnutrition, the risks of economic (price surges) and environmental (climate variability) shocks that jeopardize the availability and affordability of and access to healthy diets and feeding practices and options for dietary diversification. Alignment to 12 FYP and Global Targets The strategy and action plan will be mainstreamed into the 12 Five Year Development Plans and committed global targets, as well as aligning to the policies of all relevant sectors while also ensuring that relevant sector policies are responsive to improving the nutrition situation in the country. Inclusiveness The NNSAP will ensure that all interventions are geared to meet the requirements of all population groups. It will ensure that no one is left behind and that vulnerable populations are given equitable access to nutrition services. The strategy will ensure the services are gender responsive, disability friendly as well and ensure that the access to services due to difficult geographic locations and socioeconomic factors are minimized. 27 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 28 CHAPTER 4: OBJECTIVES 29 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) The general objective of the NNSAP is to improve nutritional security, especially for those at higher risk of malnutrition such as children, women, adolescents, the elderly and people with special needs in collaboration with multiple sectors to achieve the targets by 2025. The specific objectives of the NNSAP are as follows: 2 4 6 8 1 3 5 7 To reduce the prevalence of childhood stunting to 18% by 2023 and further reduce by 40% in the year 2025 from the baseline. To prevent undernutrition including micronutrient deficiencies in middle childhood and adolescents and adults. To reduce the prevalence of anemia in pregnant women to 18% in 2023. To monitor and evaluate nutrition security situations and related interventions across life courses. To reduce the prevalence of anemia in adolescent girls (10-19 years) to less than 18% in the year 2023. To reduce the prevalence of anemia in children 6-59 months to 29% in the year 2023. To halt the rise of overweight and obesity in all population groups. To reduce and maintain the prevalence of childhood wasting to less than 5% NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 30 The NNSAP also strives to achieve the global targets: Global targets 2025 to improve maternal, infant and young child nutrition 40% reduction in the number of children under 5 who are stunted 50% reduction of anemia in women of reproductive age 30% reduction in the low birth weight No increase in childhood overweight Increase in the rate of exclusive breastfeeding rates in the first 6 months up to at least 50% Reduce and maintain childhood wasting to less than 5% Reduce premature mortality from NCDs Nutrition as an enabler for NCD targets and objectives Diet-related global NCD targets 30% relative reduction in the mean population intake of salt/sodium25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances Halt the rise of diabetes and obesity 31 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) RE SU LT S FR AM EW OR k O ut co m es In di ca to rs Ba se lin e 20 23 20 25 Im pr ov ed n ut rit io na l st at us o f i nf an ts an d yo un g ch ild re n (p re sc ho ol a ge ) w ith sp ec ia l f oc us o n 10 00 go ld en d ay s Pr ev al en ce o f s tu nt in g un de r fi ve (0 -5 9 m on th s) 21 .2 % 18 % 13 % Pr ev al en ce o f w as tin g un de r fi ve (0 -5 9 m on th s) < 5 % < 5 % < 5 % Pr ev al en ce o f a ne m ia a m on g ch ild re n 6- 59 m on th s 43 .8 % 31 % 22 % Pr ev al en ce o f e xc lu si ve b re as tfe ed in g ch ild re n un de r s ix m on th s of a ge 51 .4 % 57 % >5 0% Pr ev al en ce o f c hi ld re n 6- 23 m on th s re ce iv in g a m in im um a cc ep ta bl e di et 11 .7 % 22 % 30 % Pr ev al en ce o f c hi ld ho od o ve rw ei gh t a nd o be si ty 2. 4% 2. 40 % 2. 40 % Im pr ov ed n ut rit io na l st at us o f s ch oo l a ge d- ch ild re n in cl ud in g m on as tic in st itu tio ns th ro ug h im pr ov ed kn ow le dg e, s ki lls a nd pr ac tic es Pr op or tio ns o f s ch oo ls im pl em en tin g m ic ro nu tr ie nt su pp le m en ta tio n an d de w or m in g pr og ra m - 80 % >9 5% Pr op or tio n of s ch oo ls a ch ie vi ng “G oo d D ie ta ry D iv er si ty Sc or e” 7. 7% 80 % >9 0% Pr op or tio n of s ch oo l c hi ld re n w ho a re o ve rw ei gh t/ ob es e 13 % <7 % <5 % Pr op or tio n of m on as tic in st itu tio ns a nd n un ne rie s im pl em en tin g nu tr iti on a dv oc ac y pa ck ag e (d ie ta ry gu id el in es , f oo d ba sk et s) - 90 % >9 5% Im pr ov ed n ut rit io na l st at us o f a do le sc en ts , yo ut h, w om en o f re pr od uc tiv e ag e, pr eg na nt a nd la ct at in g m ot he rs ; Pr ev al en ce o f a ne m ia in a do le sc en t g irl s (1 0- 19 y ea rs ) 31 .3 % 18 % 12 .8 % Pr ev al en ce o f a ne m ia a m on g w om en o f r ep ro du ct iv e ag e 34 .9 % 28 % 17 .5 % 1 2 3 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 32 Im pr ov ed n ut rit io na l st at us o f t he g en er al po pu la tio n by p ro m ot io n of h ea lth y di et s an d ph ys ic al a ct iv ity to pr ev en t o ve rw ei gh t, ob es ity a nd N CD s Ra is ed fa st in g bl oo d su ga r a m on g ad ul ts (1 5- 69 y ea rs ) 6. 4% N o ris e N o ris e M ea n sa lt in ta ke in th e po pu la tio n 8. 3 gm /d ay 7. 6 gm / da y 5. 8 gm / da y Pr ev al en ce o f a du lt ob es ity 6. 2 % N o ris e N o ris e Im pr ov ed fo od s ec ur ity , w at er s an ita tio n & hy gi en e as n ut rit io n se ns iti ve *I nc re as e in p ro du ct io n of c er ea ls 12 38 47 M T 13 10 42 M T 13 77 46 M T In cr ea se in v eg et ab le p ro du ct io n 58 69 7 M T 69 44 35 M T 69 44 35 M T In cr ea se in p ro du ct io n of fr ui ts 5 39 61 M T 75 85 5 M T 8 34 40 M T Pe rc en ta ge in cr ea se in d is tr ib ut io n of fo rt ifi ed fo od s 60 00 M T >2 0% >2 0% Se lf- su ffi ci en cy ra tio o f f le sh fo od s 0. 37 0. 4 0. 47 Se lf- su ffi ci en cy ra tio o f d ai ry p ro du ct s 0. 88 0. 88 0. 91 Se lf- su ffi ci en cy ra tio o f v eg et ab le s 86 10 0 10 0 Pe r c ap ita c on su m pt io n of e gg s 16 6 20 7 21 7 Pe rc en ta ge o f h ou se ho ld s w ith a cc es s to 2 4X 7 w at er su pp ly fo r d rin ki ng a nd m ai nt ai ni ng h yg ie ne a nd sa ni ta tio n 53 .4 7 % (R ur al ), 26 .5 8 % (U rb an ) 10 0 % 10 0 % Pe rc en ta ge o f h ou se ho ld u si ng s af el y m an ag ed sa ni ta tio n fa ci lit ie s 53 .6 % 70 % 70 % Im pr ov ed a nd s ca le d- up se rv ic es a nd p ra ct ic es re la te d to c lin ic al nu tr iti on a nd d ie te tic s Pr op or tio n of h ea lth fa ci lit ie s (w ith n ut rit io ni st / di et iti an ) i m pl em en tin g es se nt ia l n ut rit io n ca re p ac ka ge - 10 0% 10 0% Pr op or tio n of h ea lth fa ci lit ie s im pl em en tin g th e fo od se rv ic e sy st em g ui de lin es - 10 0% 10 0% 4 5 6 Im pr ov ed g ov er na nc e, po lic ie s an d m ul ti- se ct or al p ar tn er sh ip s in s up po rt o f n ut rit io n in te rv en tio ns M in im um n um be r o f N at io na l N ut rit io n Ta sk F or ce m ee tin gs c on du ct ed a nn ua lly - 2 2 Im pr ov ed m on ito rin g an d ev al ua tio n of n ut rit io n se cu rit y si tu at io n an d re la te d in te rv en tio ns N um be r o f n at io na l l ev el s ur ve ys c on du ct ed to in fo rm on th e po lic ie s an d in te rv en tio ns - 2 3 *T he la te st p ub lis he d ce ns us d at a ha s be en u se d as a b as is fo r p ro je ct ed p ro du ct io n. 7 8 33 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 34 35 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 36 CHAPTER 5: IMPLEMENTATION MODALITY 37 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) GOvERNANCE STRUCTURE Nutrition is a cross cutting issue which requires multi-system collaborative efforts of various sectors both within and outside the government. The successful implementation of NNSAP will entail effective collaboration with multiple agencies. Therefore, a National Nutrition Task Force committee (NNTF) comprising of representatives from multiple agencies would function as the custodian of NNSAP. NATIONAL NUTRITION TASk FORCE (NNTF) Director, Department of Public Health (Chairperson) Pediatrician (Technical Adviser) Chief Program Officer, School Health and Nutrition Division, Department of School Education, Ministry of Education Chief Agriculture Officer, Agriculture Production Division, Department of Agriculture, Ministry of Agriculture and Forests Chief Livestock Officer, Livestock Production Division, Department of Livestock, Ministry of Agriculture and Forests Chief Engineer, Water and Sanitation Division, Department of Engineering, Ministry of Works and Human Settlement Head, Food and Nutrition Laboratory, Royal Centre for Disease Control Representatives from development partners and non-governmental organization Other members to be co-opted as and when required 1 2 3 4 5 6 7 8 9 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 38 SECRETARIAT TO THE NNTF The Nutrition Program, DOPH, MoH under the supervision of the relevant Chief Program Officer (CPO), will be the secretariat to the NNTF. MANDATES OF THE NNTF The National Nutrition Task Force is mandated to: • Oversee and ensure the smooth implementation of the NNSAP • Act as national advisory group for all matters within the purview of the NNSAP • Meet periodically to provide technical guidance and support to ensure that the deliverables in the NNSAP are met • Conduct periodic evaluations of the NNSAP when deemed necessary and appropriate • Coordinate cross-sectoral responses and actions for routine nutrition programs and emergency nutrition preparedness IMPLEMENTATION OF NNSAP For the implementation of NNSAP, Nutrition Program, MoH will lead the coordination between all relevant sectors, while also guiding and facilitating the implementation process. The arrangement for the implementation will be as follows: Planning and budgeting: NNSAP will be incorporated in the plans of all the relevant stakeholders. The development of Annual Work Plans (AWPs) and budgets will be in line with NNSAP. In order to ensure quality implementation, important key indicators will be encouraged to be incorporated in the Governments Performance Management System (GMPS) – Annual Performance Agreement (APA) or equivalent. Coordination and management: Nutrition Program, DoPH will be responsible for coordination and management of NNSAP at the national level. The Program will also advocate and encourage the districts and other relevant stakeholders to take up planning and implementation of the NNSAP through the NNTF committee. 39 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) Information and communication: SBCC will be developed and organized to raise awareness on nutrition issues. High level decision makers including parliamentarians and other elected officials will be periodically advocated on nutrition to garner support and keep nutrition at the helm of the country’s development agenda. Monitoring: Periodic monitoring of activity implementation will be conducted during the NNTF meetings. Key indicators of NNSAP will be incorporated in the sectoral monitoring systems - Health Management Information Systems (HMIS), Education Management Information Systems (EMIS) etc. National level surveys will be conducted to evaluate the impact of NNSAP as well as inform on policies and strategies. NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 40 41 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 42 CHAPTER 6: STRATEGIC RESULT AREAS 43 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) STRATEGIC RESULT AREAS To achieve the goals set in the 12th FYP, the national health policy and other global commitments, NNSAP will play a crucial role in the successful mobilization of efforts and resources to engage and follow through in planning and implementing robust work plans. In this regard, the nutrition agenda for next five years will be shaped along the following strategies: 1. To improve the nutritional status of infants and young children (preschool age) with special focus on 1000 golden days 2. To improve the nutritional status of school aged-children including monastic institutions through improved knowledge, skills and practices 3. To improve the nutritional status of adolescents, youth, women of reproductive age, pregnant and lactating mothers 4. To improve the nutritional status of the general population by promotion of healthy diets and physical activity to prevent overweight, obesity and NCDs 5. To strengthen the food and nutrition security, water sanitation & hygiene as nutrition sensitive interventions 6. To improve and scale-up services and practices related to clinical nutrition and dietetics 7. Strengthening governance and multi-sectoral partnerships in support of nutrition interventions and have resilient systems for nutrition in emergency preparedness 8. To improve monitoring and evaluation of nutrition security situations and related interventions STRATEGIC RESULT AREA 1 To improve the nutritional status of infants and young children with special focus on 1000 golden days Malnutrition remains a major threat to the survival, growth and development of children in Bhutan. Poor nutrition in infancy and early childhood increases the risk of child morbidity and mortality, diminished cognitive and physical development marked by poor performance in school. Malnutrition also impacts on productivity later in life. Appropriately, one of the key indicators used Uptake of Essential Nutrition Interventions from conception period till two years of age will reduce infant mortality by 25%, maternal mortality by 20% and chronic malnutrition/ stunting in children by 30%. NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 44 as NKRA in the 12FYP is the prevalence of stunting among children under the age of 5 years. Malnutrition in children can be attributed to a variety of factors including poor infant and young child feeding practices, poor maternal nutrition, low access to adequate and diversified diets, childhood illnesses and inadequate access to health and nutrition services. This Plan focuses on activities that will contribute by optimal utilization of the critical ‘window of opportunity’ from pre-pregnancy until two years of age as endorsed in the 2010 UN summit resolution on nutrition. According to Lancet Nutrition Series published in 2008, if the package of Essential Nutrition Interventions is effectively accessed by mothers from the conception period and children up to two years of age and implemented on a wider scale, in the short run, infant mortality would reduce by 25%, maternal mortality by 20% and chronic malnutrition/stunting in children by 30%. Priority Areas • Promote, protect and support breastfeeding for children: early initiation of breastfeeding, exclusive breastfeeding for the first six months of baby’s life and continued breastfeeding for at least two years • Promote optimal complementary feeding with a special focus to improve the dietary diversity from locally available foods • Provide appropriate micronutrient supplements to children under five years • Strengthen growth monitoring and promotion for children under five years of age • Strengthen the screening and management of acute malnutrition, low birth weight infants and improve referral mechanism and linkage between the health facilities • Strengthen the screening and management of child development including prevention and early management of childhood illnesses • Improve advocacy and encourage community engagement to achieve optimal child nutritional status STRATEGIC RESULT AREA 2 To improve the nutritional status of school aged-children including monastic institutions through improved knowledge, skills and practices; Schools provide an ideal platform to build the human capital of the country by securing the gains from the first 1,000 days’ investment and addressing the missed growth during the catch-up phase in school going children, thereby contributing towards a holistic approach of 8,000 days. 45 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) There are evidences that well-designed school feeding programs contribute to health and nutrition, school enrollment, attendance, cognition and educational achievement which supports improved conditions for individuals and the community. School feeding promotes school participation, especially for children from hard-to-reach areas and vulnerable groups; provides a social safety net; and stimulates rural economies with schools as markets for local produce. School feeding can reduce a household’s food needs over the school year so that they have more disposable income to meet other immediate needs. Schools are a place where children learn life skills and can develop healthy dietary habits. Evidence shows that habits developed in childhood tend to persist to adulthood and even result in their transmission from one generation to another. The development of healthy dietary habits during childhood can also help to prevent diet-related diseases later in life. Creating partnerships among relevant agencies makes the best use of the available resources to improve health, nutrition and education outcomes. Linking the National Nutrition Strategy with other relevant programs on health, nutrition and school agriculture, food safety and WASH complement ongoing efforts, avoid duplication and build on synergies for a more effective and efficient implementation Besides ensuring that children receive meals in schools, the RGoB is investing in improving the nutritional quality of the meals. Improving nutrition education and healthy eating habits, addressing the double burden of over and under nutrition, and integrating school meals to local eating habits are among the programs’ objectives. Priority areas • Optimize school meals using Plus School Menu, incorporation of food fortification and strengthen linkages to local farmers, to ensure nutritional requirements of school-aged children are met • Develop and implement a comprehensive Social Behavior Communication Change (SBCC) Strategy to improve dietary and health practices for school aged children and their parents/communities • Improving school kitchen and store infrastructure and facilities in place for schools to be able to provide nutritious and safe school meals • Strengthening online, digital, monitoring and reporting systems for school health and nutrition programs to enable better programming and decision- making Well-designed programs for school aged children contribute to health and nutrition, school enrolment, attendance, cognition and educational achievement NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 46 47 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) • Capacity building of relevant staff on an integrated approach of managing school feeding and nutrition programs including food preparation, storage, food safety and WASH • Provide recommended micronutrient supplements to school aged children • Strengthening the healthy food environments in schools and monastic institutions to manage and control the marketing of unhealthy foods and beverages • Implement the required physical activity recommendations including sports as part of school curriculum STRATEGIC RESULT AREA 3 To improve the nutritional status of adolescents, women of reproductive age, pregnant and lactating mothers The National Nutrition Survey (2015) reported that 27% of pregnant women and 31.3% of adolescent girls were anemic. Nutritional status of women of reproductive age, pregnant and lactating mothers is of significant importance for the healthy delivery and development of babies. Realizing the need to improve the nutritional status of pregnant and lactating mothers, the Ministry of Health has prioritized on a holistic and comprehensive approach to strengthen the mother and child health outcomes through the ‘Accelerating mother and child health program’ where, the nutrition of pregnant and lactating mothers is prioritized. Further, the improvement of nutritional status of adolescent girls, women in reproductive age, pregnant and lactating mothers constitute some of the important indicators for the national key result area. The National Adolescent Health Program in its effort to improve the nutritional status of adolescents complements the National Nutrition Program by supporting and promoting the importance of nutrition among adolescents through Adolescent Friendly Health Services (AFHS). Reduction of anemia among adolescents is one of the priorities of the program in the 12th FYP. Priority Areas • Improving and strengthening the coverage of recommended 8 ANC visits, 4 PNC, and early booking for the pregnant women and provision of nutrition services at each visit in line with the WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience Improving nutritional status of adolescents, women of reproductive age, pregnant and lactating mothers is a priority NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 48 • Improving the counselling services on nutritious and safe diets, physical activity and rest and weight gain • Promoting, strengthening and supporting the supply and consumption of multiple micronutrients including Iron Folic Acid tablets, Vitamins and calcium lactate for pregnant women • Strengthening the management and screening of anemia for adolescent girls, and women in the reproductive age group • Strengthening and expanding the implementation of package of preconception nutritional care • Strengthening and expanding Adolescent Friendly Health Services to deliver nutrition services • Improving advocacy to promote healthy dietary practices among adolescents • Reducing micro-nutrient deficiency status among the adolescents STRATEGIC RESULT AREA 4 To improve the nutritional status of the general population by promotion of healthy diets and physical activities to prevent non-communicable diseases; The prevalence of diet related non-communicable diseases has been on the rise. The steps survey 2019 indicated around 45% of the Bhutanese populating aged 15-69 years are either overweight or obese. Furthermore, the survey indicates that almost 9 out of every 10 people do not consume the recommended fruits and vegetables. Coupled with engagement of unhealthy behavioral practices such as physical inactivity, consumption of alcohol and irregular health screening has given rise to the NCD menace in Bhutan. The annual health bulletin of 2019 reported 71% of all deaths as a direct result of NCDs. Priority Areas • Implementing a comprehensive strategy and guideline for prevention, management and control of diet related NCDs • Improve capacity of service providers on prevention, management and control of diet related NCDs through capacity building as well as ensuring a steady supply chain of necessary equipment • Creating awareness for both the general public as well as policy makers on the importance of prevention, management and control of diet related NCDs Nine out of every ten people do not consume the recommended fruits and vegetables 49 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 50 • Involving community leaders in the prevention and control of NCDs • Ensuring consumer rights to access good quality and appropriate foods in line with the provisions of the consumer protection act • Ensuring trade and marketing policies are geared towards providing healthy and nutritious foods • Ensuring consumers’ right to information through labelling of foods STRATEGIC RESULT AREA 5 To strengthen the food and nutrition security, water sanitation & hygiene as nutrition sensitive interventions The RNR sector comprising agriculture, livestock and forests is considered one of the five important drivers of economic development in terms of its potential to ensure self- reliance (EDP, 2016). It provides engagement to 49.9% of the total employed population (LFS, 2020) and contributes to the Bhutanese food basket comprising 53 commodities contributing to 70% of the domestic food requirement (MoAF, 2020). Farmers hold an average farm size of 2.22 acres, practicing mostly subsistence to semi-subsistence integrated farming systems. Over the last two plan periods, farming in Bhutan has seen a dynamic shift from subsistence nature to commercialized farming. The Food and Nutrition Security Policy of Kingdom of Bhutan, 2014 underpins the sectoral development and envisions that ‘all people living in Bhutan at all times have physical, economic and social access to safe and adequate nutritious food for a healthy and active life contributing to realization of Gross National Happiness’. Bhutan has already achieved self-sufficiency in fruits (132%), potatoes (162%) and eggs (100%) and self-sufficiency for other food commodities are on a progressive trajectory (MoAF, 2020). With a vegetable self-sufficiency rate of about 88%, availability is not an issue rather it is about personal preference for consumption and affordability. It is reported that 97.3 % of the total population is sufficient with food during 12 months (BLSS, 2017). This translates to 2.7% of the total population experiencing food insufficiency in the country. Food shortage is reportedly experienced by the rural inhabitants, especially during the months of May-August. Further, with rapid urbanization and change in food consumption pattern, there is an increased demand for processed food and meat which cannot be met by local production. As an import dependent economy that relies heavily on imported food to meet our nutritional demand, food safety is a major area of concern. Additional efforts and emphasis on ‘All people living in Bhutan at all times have physical, economic and social access to safe and adequate nutritious food for a healthy and active life contributing to realization of Gross National Happiness’ 51 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 52 the nutritional aspects of food being produced need to be incorporated in plans and programs. Water is a fundamental human right and an essential resource that supports life and livelihoods. Potable water is required for drinking and sanitation, food preparation and for maintaining personal hygiene. As per the Water Act of Bhutan 2011 and the Water Regulation of Bhutan 2014, water for drinking and sanitation is the first priority for water allocation. Additionally, National Sanitation and Hygiene Policy 2020 is developed with the objective to achieve universal coverage and access to sustainable services. Therefore, provision of adequate and reliable, clean drinking water and improved sanitation is an essential service that the state needs to ensure its citizens. Priority Areas • Improve the availability of – physical and economic access to – and the consumption of diversified food commodities (cereals, legumes) and fruits and vegetables through enhanced production • Improve the availability of – physical and economic access to –– and the consumption of diversified animal source proteins • Promote food diversification and fortification • Ensuring food safety at all levels • Increase access to safe drinking water • Increase access to safe and sustainable improved sanitation services • Improve hygiene behavior practices and their management STRATEGIC RESULT AREA 6 To improve and scale-up services and practices related to clinical nutrition and dietetics Optimal nutrition care should be the first line of nutrition intervention in disease management and should be integrated as a critical and important component of health care. Clinical nutrition and dietetics services given at health care institutions can be complemented through strengthening follow-up and linkages at the community level and including promotive, preventive and nutrition rehabilitative services Water is a fundamental human right and an essential resource that supports life and livelihoods Optimal nutrition care should be the first line of nutrition intervention in disease management and should be integrated as a critical and important component of health care 53 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) The Royal Government of Bhutan provides free meals to all the patients requiring hospital admission. Adequate nutrition during illnesses have an important role in the health outcomes of the patients. Studies show that patients receiving nutritionally sound meals have faster recovery, shorter hospital stays and ultimately reduced costs. However, some critically ill patients are not able to feed orally and they must be provided nutrition through an enteral and or parenteral route. Thus, the strategy focuses on providing nutritional support to all patients through provision of different types of diet. It is also equally important to provide nutrition education to other health workers as many health facilities do not have nutritionists and they play an important role as nutrition educators in the community. Priority areas • Improve the hospital food service system • Standardize the implementation of Medical Nutrition Therapy (MNT) including enteral and parenteral nutrition • Advocating and familiarizing health staff on clinical nutrition • Participation in the community nutrition initiatives • Promoting continued professional development and improving coordination among nutrition professionals STRATEGIC RESULT AREA 7 Strengthening governance and multi-sectoral partnerships in support of nutrition interventions and have resilient systems for nutrition in emergency preparedness Malnutrition is a cross-cutting issue requiring multi-system, multi-agency partnerships including; MoAF, MoE, MoEA, MoH, NGOs among others. Coordinating efforts to implement nutrition interventions is key to achieving optimal nutritional status of the population. Thus, the Nutrition program must look beyond the health sector and address many of the key issues through an integrated approach with multiple relevant sectors. Priority Areas • Establishing a platform for multi-sectoral coordination for implementing and strategizing nutrition interventions across all sectors and levels • Identifying and empowering all relevant sectors to buy-in the nutrition agenda • Conducting regular planning and review meetings to align the annual nutrition planning process in alignment with nutrition action plan • Advocacy for partnerships and resource mobilization • Strengthen preparedness for nutrition in emergency situations NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 54 STRATEGIC RESULT AREA 8 Monitoring and evaluating nutrition security situation and related interventions Monitoring and evaluation are important in measuring program performance and evaluating the impact of interventions. It includes routine recording and reporting of important nutrition indicators as well as generating evidence to assess the impact and performance of the interventions periodically. The evidence generated will be useful for decision making and guiding the implementation of nutrition programs. Priority areas • Strengthen feedback mechanisms on nutrition information among nutrition stakeholders • Strengthen and mainstream nutrition information system with DHIS 2 platform • Conduct periodic nutrition surveys and need-based assessment/ research to inform policy, program design and implementation 55 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) AC TI ON P LA NS SR A 1: Im pr ov in g th e nu tr iti on s ta tu s in fa nt s an d yo un g ch ild re n (w ith s pe ci al fo cu s on 1 00 0 go ld en d ay s) Ac tio n Pl an s O ut pu t i nd ic at or s Ba se lin e Ta rg et s Ye ar Re sp on si bi lit y Co lla bo ra tin g pa rt ne rs Es tim at ed Co st (N u in m ill io n) 1 2 3 4 5 1. 1 Ex pa nd th e M ot he r a nd Ba by -f rie nd ly h ea lth fa ci lit y in iti at iv e (M BF H I) fo r e ar ly in iti at io n of b re as tfe ed in g an d m on ito rin g ex cl us iv e br ea st -f ee di ng Pr op or tio n of he al th fa ci lit ie s im pl em en tin g M BF H I i ni tia tiv e N A 90 % X X X X X N P (M oH ) RH , U N IC EF ,D H O s, M CH 10 1. 2 Ad vo ca te to in co rp or at e W H O B re as tm ilk C od e an d su bs eq ue nt W H A re so lu tio ns in re le va nt AC TS a nd P ol ic ie s N um be r o f a ct s an d po lic ie s w ith W H O B re as tm ilk Co de c la us e N A 1 X X X X X N P RH , U N IC EF ,D H O s, M CH 0. 5 1. 3 Sc al e up s pr in kl es p ro je ct (m ul tip le m ic ro nu tr ie nt po w de r) fo r m ic ro nu tr ie nt su pp le m en ta tio n fo r ch ild re n 6- 23 m on th s Pr op or tio n of he al th fa ci lit ie s im pl em en tin g sp rin kl es p ro gr am N A 99 % X X X X X N P (M oH ) RH , U N IC EF , D H O s, M CH 40 1. 4 St re ng th en th e U 5 gr ow th m on ito rin g pl us p ac ka ge (g ro w th m on ito rin g, vi ta m in A s up pl em en ta tio n, de w or m in g an d co un se lli ng ) Pr op or tio n of he al th fa ci lit ie s im pl em en tin g G M pl us p ro gr am N A 99 % X X X X X N P (M oH ) RH , U N IC EF , D H O s, M CH 30 1. 5 St re ng th en IY CF c ou ns el in g an d im pr ov e qu al ity o f co m pl em en ta ry fe ed in g fo r c hi ld re n 6- 59 m on th s by p ro m ot io n of lo ca lly av ai la bl e fo od s/ re ci pe s. Pr op or tio n of he al th fa ci lit ie s co nd uc tin g co un se lli ng se ss io n on IY CF (a nd C F) N A 97 % X X X X X N P (M oH ) RH , U N IC EF , D H O s, M CH 20 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 56 1. 6 St re ng th en m an ag em en t o f Se ve re A cu te M al nu tr iti on (S AM ) a nd M od er at e Ac ut e M al nu tr iti on (M AM ) i n H os pi ta ls a nd s tr en gt he n re fe rr al m ec ha ni sm N um be r o f N RU s im pl em en tin g th e tr ea tm en t p ro to co l fo r S AM a nd M AM N A 20 X X X X N P (M oH ) RH , U N IC EF , D H O s, M CH 3 1. 7 St re ng th en id en tifi ca tio n, cl as si fic at io n an d tr ea tm en t o f c hi ld ho od ill ne ss th ro ug h IM N CI pr og ra m Pr op or tio n of B H U ’s im pl em en tin g IM N CI p ro gr am N A >9 0% X X X X X CH P (M oH ) RG oB , U N IC EF , W H O, F N PH , D M S 21 .0 1. 8 Sc al e up C 4C D p lu s fo r ho lis tic c hi ld d ev el op m en t th ro ug h in iti at io n of e ar ly st im ul at io n Pr op or tio n of he al th fa ci lit ie s N A 20 X X X X X CH P (M oH ) RG oB , U N IC EF , W H O, S av e th e Ch ild re n, D M S 41 .4 1. 9 Im pl em en t S BC C ca m pa ig n fo r c om m un ity e ng ag em en t to im pr ov e ch ild fe ed in g (E ng ag em en t w ith lo ca l le ad er s (g up s, ts ho gp as an d M ST F/ CB SS ; en ga ge m en t w ith fa ith - ba se d ag en ci es ; m as s m ed ia , V H W s) N o of S BC C ca m pa ig ns co nd uc te d N A 5 X X X X H PD / N P/ N P, U N IC EF , W H O, 8 57 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 58 SR A 2: Im pr ov in g th e nu tr iti on al s ta tu s of s ch oo l g oi ng c hi ld re n an d m on as tic in st itu tio ns th ro ug h im pr ov ed k no w le dg e, s ki lls a nd pr ac tic es , i nc lu di ng im pr ov ed d ie ts Ac tio n Pl an s O ut pu t i nd ic at or s Ba se lin e Ta rg et s Ye ar Re sp on si bi lit y Co lla bo ra tin g pa rt ne rs Es tim at ed Co st (N u in m ill io n) 1 2 3 4 5 Sc ho ol C hi ld re n 2. 1 O pt im iz e sc ho ol m ea ls us in g Pl us S ch oo l M en u, in co rp or at io n of fo od fo rt ifi ca tio n an d st re ng th en lin ka ge s to lo ca l f ar m er s, to e ns ur e nu tr iti on al re qu ire m en ts Pr op or tio n of s ch oo ls pr ov id in g nu tr iti ou s m ea ls 0 80 % X X X X X SH N D (M oE ) M oH , M oE , M oA F, BA FR A, FC BL , W FP 6. 57 2. 2 D ev el op a nd im pl em en t co m pr eh en si ve S oc ia l Be ha vi or C om m un ic at io n Ch an ge (S BC C) S tr at eg y to im pr ov e di et ar y an d he al th p ra ct ic es fo r s ch oo l ch ild re n an d th ei r p ar en ts / co m m un iti es Pe rc en ta ge o f ac tiv iti es in th e st ra te gy c om pl et ed N on e 60 % X X X X X SH N D (M oE ) M oH , M oE , M oA F, BA FR A, FC BL , W FP , U N IC EF 36 .5 2. 3 Im pr ov e sc ho ol k itc he n an d st or e in fr as tr uc tu re an d fa ci lit ie s fo r s ch oo ls to pr ov id e nu tr iti ou s an d sa fe sc ho ol m ea ls Pr op or tio n of sc ho ol s m ee tin g th e m in im um st an da rd s fo r s ch oo l ki tc he n, s to re , f oo d co m m od iti es s up pl y an d pr of es si on al co ok s (a t l ea st o ne / sc ho ol ) N A 40 % X X X X X SH N D (M oE ) M oH , M oE , M oA F, F CB L, W FP 14 6 2. 4 D ev el op a nd im pl em en t G oo d Fo od S af et y Pr ac tic es a nd St an da rd s in S ch oo ls Pr op or tio n of s ch oo ls im pl em en tin g go od fo od s af et y st an da rd s N A 95 % X X X X X SH N D (M oE BA FR A, F CB L, Sc ho ol s, D EO s 36 .5 59 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) 2. 5 St re ng th en o nl in e, d ig ita l, m on ito rin g an d re po rt in g sy st em s fo r s ch oo l h ea lth an d nu tr iti on p ro gr am s to en ab le b et te r p ro gr am m in g an d de ci si on -m ak in g. Pr op or tio n of s ch oo ls re po rt in g th ro ug h th e on lin e sy st em N A 95 % X X X X X SH N D (M oE ) W FP 4. 38 2. 6 Ca pa ci ty b ui ld in g of re le va nt st af f o n in te gr at ed a pp ro ac h of m an ag in g sc ho ol fe ed in g an d nu tr iti on p ro gr am s in cl ud in g fo od p re pa ra tio n, st or ag e, fo od s af et y an d W AS H . Pr op or tio n of s ch oo ls w ith tr ai ne d st af f N A 80 % X SH N D (M oE ) M oH , M oE , M oA F, BA FR A, FC BL , W FP 1 4. 6 2. 7 Pr ov id e re co m m en de d m ic ro nu tr ie nt s up pl em en ts to s ch oo l c hi ld re n Pr op or tio n of s ch oo ls im pl em en tin g m ic ro nu tr ie nt su pp le m en ta tio n an d de w or m in g pr og ra m N A 10 0% X X X X X SH N D (M oE ) M oH , M oE , W H O 10 .0 2. 8 En su re a cc es s to s af e dr in ki ng w at er a nd c le an to ile ts a nd e du ca tio n in sa ni ta tio n an d hy gi en e ba se d on W AS H in s ch oo l gu id el in es Pr op or tio n of s ch oo ls im pl em en tin g th e pr og ra m N A 95 % X X X X X SH N D (M oE ) M oH , M oE , 2 0. 0 2. 9 St re ng th en s ch oo l f ee di ng su pp ly c ha in to e ns ur e pr oc ur em en t a nd d is tr ib ut io n of s af e an d nu tr iti ou s fo od c om m od iti es w hi le m in im iz in g fo od lo ss . Pe rc en ta ge o f sc ho ol s ef fe ct iv el y im pl em en tin g th e Sc ho ol F ee di ng a nd N ut rit io n Pr og ra m m e N A 10 0% X X X X X SH N D (M oE ) M oH , M oE , M oA F, F CB L, W FP 36 .5 M on as tic In st itu tio ns 2. 10 As se ss h ea lth a nd n ut rit io n st at us o f t he m on ks a nd nu ns to g ui de h ea lth a nd nu tr iti on p ro gr am m in g fo r m on ks a nd n un s N o. o f a ss es sm en ts co nd uc te d 0 1 X X X X H PD (M oH ) N ut rit io n Pr og ra m / D ra ts ha ng Lh en ts ho g/ W FP 1. 0 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 60 2. 11 D ev el op a nd im pl em en t nu tr iti on a dv oc ac y pa ck ag e in th e m on as tic in st itu tio ns an d nu nn er ie s (D ie ta ry g ui de lin es , f oo d ba sk et s et c) Pr op or tio n of m on as tic in st itu tio ns an d nu nn er ie s im pl em en tin g th e ad vo ca cy p ac ka ge 0 90 % x x x x x H PD (M oH ) N ut rit io n Pr og ra m / D ra ts ha ng Lh en ts ho g/ W FP 2. 5 2. 12 Es ta bl is h na tio na l c om m itt ee in D ra ts ha ng L he nt sh og to st ee r t he n ut rit io n an d he al th ag en da fo r m on ks a nd n un s N at io na l c om m itt ee es ta bl is he d 0 1 x x x x x H PD (M oH ) D L 5. 0 2. 13 Ca pa ci ty B ui ld in g of dr at sh an gs /n un ne rie s to c oo rd in at e, a dv oc at e an d de liv er k ey h ea lth a nd nu tr iti on in te rv en tio ns (h ea lth c oo rd in at or s) Pr op or tio n of D ra ts ha ng s w ith fu nc tio na l h ea lth co or di na to rs 90 % x x x x x H PD (M oH ) N ut rit io n Pr og ra m / D ra ts ha ng Lh en ts ho g 1. 2 2. 14 In iti at e a sy st em at ic h ea lth sc re en in g an d re fe rr al m ec ha ni sm fo r d ra ts ha ng s an d nu nn er ie s Pr op or tio n of m on as tic in st itu tio ns im pl em en tin g th e pr og ra m 0 90 % x H PD (M oH ) N ut rit io n Pr og ra m / D ra ts ha ng Lh en ts ho g 6. 5 2. 15 Im pl em en t m ic ro nu tr ie nt su pp le m en ta tio n or fo od fo rt ifi ca tio n in iti at iv es to re du ce m ic ro nu tr ie nt de fic ie nc ie s Pr op or tio n of m on as tic in st itu tio ns im pl em en tin g th e pr og ra m 0 90 % X X X X X H PD (M oH ) N ut rit io n Pr og ra m / D ra ts ha ng Lh en ts ho g 73 2. 16 Im pr ov e Fo od H yg ie ne a nd Sa ni ta tio n at M on as tic In st itu tio ns th ro ug h aw ar en es s an d in tr od uc in g go od fo od h yg ie ne a nd sa ni ta tio n pr ac tic es Pr op or tio n of m on as tic in st itu tio ns w ith g oo d fo od hy gi en e an d sa ni ta tio n pr ac tic es 0 90 % BA FR A D ra ts ha ng Lh en ts ho g 5 M 61 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 62 SR A 3: Im pr ov in g th e nu tr iti on s ta tu s of a do le sc en ts , w om en o f r ep ro du ct iv e ag e, p re gn an t a nd la ct at in g w om en Ac tio n Pl an s O ut pu t i nd ic at or s Ba se lin e Ta rg et s Ye ar Re sp on si bi lit y Co lla bo ra tin g pa rt ne rs Es tim at ed Co st (N u in m ill io n) 1 2 3 4 5 Ad ol es ce nt s 3. 1 Sc al e up th e im pl em en ta tio n of m in im um n ut rit io n pa ck ag e fo r a do le sc en t g irl s N o. o f H Fs p ro vi di ng m in im um n ut rit io n pa ck ag e fo r ad ol es ce nt g irl s 7 22 X X X X X AH P N ut rit io n Pr og ra m & U N IC EF 0. 7 3. 2 D ev el op a nd im pl em en t ad vo ca cy p ac ka ge s on he al th y di et . N o. o f A FH S pr ov id in g ad vo ca cy on h ea lth y di et N A 22 X X X X X AH P N ut rit io n Pr og ra m & U N IC EF 1. 0 3. 3 D ev el op a nd im pl em en t m as s m ed ia a dv oc ac y on h ea lth y di et s fo r a do le sc en ts . N o. o f m as s m ed ia c am pa ig ns co nd uc te d N A 5 X X X X X AH P H PD & N ut rit io n pr og ra m 10 .0 3. 4 Im pr ov e ac ce ss to h ea lth in fo rm at io n an d ed uc at io n fo r ‘ at ri sk a do le sc en ts ’ b y de ve lo pi ng a nd im pl em en tin g a Pe er B as ed A do le sc en t H ea lth E du ca tio n Pr og ra m b y us in g IC T to ol s N o. o f t ar ge te d si te s im pl em en tin g th e Pe er E du ca tio n Pr og ra m N A 5 X X X X X AH P H PD , N ut rit io n, U N IC EF 1. 5 3. 5 En ha nc e th e en ga ge m en t of F am ily a nd C om m un ity M em be rs in c om m un ity - ba se d in te rv en tio ns to re sp on d to th e N ut rit io na l ne ed s of th e ad ol es ce nt s N o. o f C om m un iti es pr om ot in g Ad ol es ce nt H ea lth N A 5 X X X X X AH P H PD , U N IC EF , D LG , Co m m un ity 1. 2 3. 6 D ev el op a nd in st itu te nu tr iti on p ro gr am in g; fo rt ifi ed fo od s, fo od b as ke t, ad vo ca cy an d m on ito rin g sy st em s in te rt ia ry in st itu te s Pr op or tio n of te rt ia ry in st itu te s w ith n ut rit io n pr og ra m m in g N A 10 0 X X X X X N P RU B, KG U M SB , M O LH R 3. 0 63 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) 3. 7 Pr ov id e re co m m en de d m ic ro nu tr ie nt s up pl em en ts to a do le sc en t g irl s in te rt ia ry in st itu te s Pr op or tio n of te rt ia ry in st itu te s im pl em en tin g m ic ro nu tr ie nt su pp le m en ta tio n pr og ra m N A 10 0 X X X X X N P RU B, KG U M SB , M O LH R 10 .0 W om en o f r ep ro du ct iv e ag e 3. 8 Sc al e up th e im pl em en ta tio n of P re -c on ce pt io n Vo lu nt ar y N ut rit io n Se rv ic e Pa ck ag e fo r w om en o f r ep ro du ct iv e ag e Pe rc en ta ge o f H Fs im pl em en tin g pr e- co nc ep tio n vo lu nt ar y nu tr iti on s er vi ce pa ck ag e fo r w om en of re pr od uc tiv e ag e N A 90 % X X X X X RM N H RM N H , N ut rit io n an d U N IC EF 0. 8 3. 9 Sc re en in g an d m an ag em en t of a ne m ia in th e w om en o f re pr od uc tiv e ag e du rin g ou t- re ac h ca m ps N o. o f o ut re ac h ca m ps c on du ct in g sc re en in g an d m an ag em en t o f an em ia in th e w om en of re pr od uc tiv e ag e N A 12 0 X X X X X D M S RM N H 1. 5 Pr eg na nt w om en 3. 10 St re ng th en a nd su st ai n m ic ro nu tr ie nt su pp le m en ta tio n pr og ra m (Ir on F ol ic A ci d, C al ci um a nd Vi ta m in s) Pr op or tio n of p re gn an t w om en re ce iv in g su pp le m en ta tio n pr og ra m 90 % >9 7% X X X X X RM N H N ut rit io n an d RM N H 0. 6 3. 11 En ha nc e qu al ity o f A N C by s tr en gt he ni ng n ut rit io n co un se lli ng a nd p re gn an cy w ei gh t m on ito rin g Pe rc en ta ge in cr ea se in A N C co ve ra ge 26 80 % X X X X X RM N H N ut rit io n an d RM N H 1 3. 12 Im pr ov e D ie ta ry D iv er si ty fo r pr eg na nt w om en th ro ug h ed uc at io n an d co un se lli ng Pe rc en ta ge o f H Fs pr ov id in g ed uc at io n an d co un se lin g on di et ar y di ve rs ity N A >7 0% X X X X X RM N H N ut rit io n an d RM N H 1. 2 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 64 3. 13 St re ng th en L in e lis tin g fo r p re gn an t w om en a nd ea rly b oo ki ng o f A N C an d co m pl et io n of P N C vi si ts Pr op or tio n of pr eg na nt w om en bo ok ed fo r A N C an d co m pl et io n of P N C vi si ts 51 % >9 0% X X X X X RM N H RM N H 1. 0 3. 14 Sc al e up th e on lin e M CH tr ac ki ng s ys te m Pr op or tio n of he al th fa ci lit ie s im pl em en tin g th e M CH tr ac ki ng s ys te m N A 95 % X X X X X RM N H RM N H La ct at in g m ot he rs 3. 15 Es ta bl is h la ct at io n su pp or t un it in E m O N C ce nt er s N um be r o f E m O N C ce nt er s w ith La ct at io n un it 1 6 X X X X RM N H RM N H 1. 5 3. 16 Im pl em en t N ut rit io n Co un se lli ng p ac ka ge fo r Pr eg na nt a nd la ct at in g w om en (M CH G ui de lin e) Pr op or tio n of H Fs pr ov id in g N ut rit io n Co un se lli ng p ac ka ge ba se d on M CH gu id el in e N A 95 % X X X X X N P R M N H 1. 0 3. 17 St re ng th en s up pl em en ta tio n pr og ra m fo r l ac ta tin g w om en (C om pl et e Im pl em en ta tio n of M CH G ui de lin e) Pr op or tio n of la ct at in g w om en re ce iv in g su pp le m en ta tio n 90 % >9 7% X X X X X RM N H RM N H a nd N ut rit io n 0. 8 3. 18 Sc re en in g an d m an ag em en t of o ve rw ei gh t a nd o be se la ct at in g m ot he rs d ur in g gr ow th m on ito rin g an d im m un iz at io n vi si ts (im pl em en ta tio n of P EN Pr ot oc ol ) Pr op or tio n of H F im pl em en tin g th e ac tiv ity N A 95 % X X X X X RM H H RM N H , L SR D an d N ut rit io n 1. 5 65 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 66 SR A 4: Im pr ov in g th e nu tr iti on al s ta tu s of th e po pu la tio n by p ro m ot in g he al th y di et s an d ph ys ic al a ct iv iti es to p re ve nt N CD s Ac tio n Pl an s O ut pu t i nd ic at or s Ba se lin e Ta rg et s Ye ar Re sp on si bi lit y Co lla bo ra tin g pa rt ne rs Es tim at ed Co st (N u in m ill io n) 1 2 3 4 5 4. 1 Re vi ew a nd re vi se th e fo od ba se d di et ar y gu id el in e Re vi se d gu id el in e 1 1 X X X X X LS RD M oE A, B AF RA , M oA , F N PH , N P 1. 0 4. 2 Ro ll ou t n at io na l s al t, fa t a nd su ga r s tr at eg y % o f s ch oo ls /h ea lth fa ci lit ie s im pl em en t- in g th e gu id el in e 0 95 % X X X X X LS RD P M oE A, B AF RA , M oA , F N PH , N P 10 4. 3 Re vi ew a nd re vi se n ut rit io n co m po ne nt s fo r p re -s er vi ce an d in -s er vi ce c ur ric ul um of h ea lth p ro fe ss io na ls a nd fo rm al a nd n on - fo rm al ed uc at io n Re vi se d Cu rr ic ul um 0 1 X X X X X N P M O E KG U M SB 0. 5 4. 4 Se ns iti ze p ol ic y m ak er s on th e fo od b as ed d ie ta ry g ui de - lin e in cl ud in g fo od s af et y N um be r o f s en si tiz a- tio ns c on du ct ed 0 5 X X X X X LS RD H PD .0 5 4. 5 Co nd uc t b eh av io r c ha ng e co m m un ic at io n w or ks ho ps fo r t he lo ca l l ea de rs N um be r o f B CC w or ks ho ps c on du ct - ed N A 5 X X X X X LS RD H PD , N P .0 5 4. 6 Su pp ly s ta di om et er a nd w ei gh in g sc al e to th e PH C’ s Pe rc en ta ge o f h ea lth fa ci lit ie s w ith B M I ap pa ra tu s N A 95 % X X X X X LS RD D oM SH I 30 4. 7 Ad vo ca te a nd p ro m ot e ph ys ic al a ct iv ity a m on g th e ge ne ra l p op ul at io n N um be r o f a dv o- ca ci es o n ph ys ic al ac tiv ity N A 5 X X X X X LS RD DY S, B oC 1. 0 4. 8 Ro ll ou t P EN h ea rt s pr ot oc ol in a ll he al th fa ci lit ie s in th e co un tr y Pr op or tio n of h ea lth fa ci lit ie s im pl em en t- in g th e pr ot oc ol N A 10 0 X X X X X LS RD KG U M SB 4. 25 4. 9 Co nd uc t S TE PS R is k fa ct or Su rv ey N um be r o f s ur ve ys co nd uc te d 2 1 X X LS RD M oH , F N PH , D ev el op in g pa rt ne rs 50 67 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) 4. 10 D ev el op a nd im pl em en t ap pr op ria te fo od la be lin g st an da rd s N um be r o f f oo ds w ith s ta nd ar d fo od la be ls 0 50 X X X O CP N P LS RD BA FR A BS B 1. 5 4. 11 Pr om ot e an d re gu la te fo od en vi ro nm en t t o en su re he al th y fo od b eh av io r N um be r o f c on su m er aw ar en es s co nd uc t- ed 0 30 X X X X O CP N P, L SR D P, 0. 5 4. 12 En su re tr ad e an d m ar ke tin g po lic ie s ar e ge ar ed to w ar ds pr ov id in g he al th y an d nu tr i- tio us fo od s N o of tr ad e an d m ar ke tin g po lic ie s ge ar ed to w ar ds he al th y an d nu tr i- tio us fo od s 0 2 X X X X D oT N P, LS RD P 0. 5 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 68 SR A 5: Im pr ov in g fo od s ec ur ity a nd w at er , s an ita tio n an d hy gi en e (W AS H ) Ac tio n Pl an s O ut pu t i nd ic at or s Ba se lin e Ta rg et s Ye ar Re sp on si bi lit y Co lla bo ra tin g pa rt ne rs Es tim at ed Co st (N u in m ill io n) 1 2 3 4 5 5. 1 In cr ea se p ro du ct io n of c er ea ls (m ai ze , ric e, q ui no a, w he at , ba rle y) Pe rc en ta ge in cr ea se fr om ba se lin e 12 4, 6 26 (M T) 45 % X X X X X D oA , M oA F M oH /L G 10 5. 2 In cr ea se p ro du ct io n of fr ui t c ro ps (a pp le , m an da rin , p ea ch , pl um b, b an an a) Pe rc en ta ge in cr ea se fr om ba se lin e 51 , 3 37 (M T) 45 % X X X X X D oA , M oA F M oH // LG 20 5. 3 In cr ea se p ro du ct io n of v eg et ab le s Pe rc en ta ge in cr ea se fr om ba se lin e 48 , 7 98 (M T) 45 % X X X X X D oA , M oA F M oH /L G 20 5. 4 In tr od uc e an d pr om ot e fo od c ro ps as p ar t o f f oo d di ve rs ifi ca tio n N um be r o f cr op v ar ie tie s re le as ed N os 25 X X X X X D oA , M oA F M oH /L G 0. 50 5. 5 Re vi ew a nd im pl e- m en t o f c on ce pt fo r m od el n ut rit io n ga rd en in th e co m - m un iti es N um be r o f m od el n ut rit io n ga rd en p ro - m ot ed - 45 X X X X X D oA , M oA F M oH /L G / M oE /W FP 8. 0 5. 6 Pr om ot e nu tr iti on ga rd en in s ch oo ls nu m be r o f sc ho ol s im pl e- m en tin g th e sc ho ol n ut rit io n ga rd en s 28 0 33 0 X X X X X D oA , M oA F M oH /L G / M oE /W FP 6. 0 5. 7 Pr om ot e or ga ni c fa rm in g fo r n ut ri- tio us a nd s af e fo od Pe rc en ta ge in cr ea se in pr od uc tio n of or ga ni c fo od 70 0 (M T) 57 00 X X X X X D oA , M oA F M oH /L G / M oE /D oL / D oF PS /W FP 25 0 69 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) 5. 8 In tr od uc e nu tr i- en t d en se fo od to sc ho ol s Pr op or tio n of no n- ric e ce re - al s re pl ac ed in sc ho ol m ea ls N A >1 5% X X X X X D oA /M O AF M oH /M O E 5. 9 In cr ea se m ea t pr od uc tio n (c hi ck - en , P or k, fi sh , a nd ch ev on ) Se lf- su ffi ci en cy ra tio o f M ea t 37 % 47 % X X X X X D oL / M oA F D zo ng kh ag / LG / M oH 10 .5 5 5. 10 In cr ea se p er c ap ita eg g co ns um pt io n P er C ap ita e gg Co ns um pt io n 16 6 eg gs 20 7 eg gs pe r ca pi ta X X X X X D oL / M oA F D zo ng kh ag / LG / M oH 8. 11 5. 11 En ha nc e da iry pr od uc tio n (m ilk , ch ee se a nd b ut te r) Se lf- su ffi ci en cy ra tio o f d ai ry pr od uc ts 88 % 91 % X X X X X D oL / M oA F D zo ng kh ag / LG / M oH 10 .5 5 5. 12 En ha nc e lin ka ge s of p ro du ce r g ro up s w ith m ar ke ts N os o f b us i- ne ss li nk ag es cr ea te d N os 5 0 X X X X X D AM C, M oA F M oH /M oE / LG /W FP 26 5. 13 Ac ce ss to im pr ov ed sa ni ta tio n fa ci lit ie s Pe rc en ta ge o f ru ra l h ou se - ho ld s w ith ac ce ss to im pr ov ed s an i- ta tio n 84 % 95 % X X X X X RS AH P U N IC EF S N V 4. 5 5. 14 Im pr ov in g ac ce ss to h an d w as hi ng fa ci lit ie s w ith s oa p an d w at er Pe rc en ta ge o f ru ra l h ou se - ho ld s w ith ac ce ss to h an d w as hi ng fa ci l- iti es w ith s oa p an d w at er >8 0% >9 0% X X X X X RS AH P U N IC EF S N V NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 70 5. 15 Ac ce ss to 2 4X 7 sa fe d rin ki ng w at er en su re d. Pe rc en ta ge o f ru ra l a nd u rb an ho us eh ol ds w ith a cc es s t0 2 4X 7 sa fe dr in ki ng w at er . 53 .4 7 % (r ur al ), 26 .5 8 % (U rb an ) 10 0% X X X X X M oW H S an d LG s G N H C, M oF , D ev el - op m en t Pa rt ne rs 50 00 .0 5. 16 H ou se ho ld u si ng sa fe ly m an ag ed sa ni ta tio n fa ci lit ie s Pe rc en ta ge o f ur ba n ho us e- ho ld s us in g sa fe ly m an ag ed sa ni ta tio n fa ci lit ie s. 53 .6 % 70 % X X X X X M oW H S, LG s G N H C, M oF , D ev el - op m en t Pa rt ne rs 50 .0 71 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 72 SR A 6: S tr en gt he ni ng c lin ic al n ut rit io n Ac tio n Pl an s O ut pu t i nd ic at or s Ba se lin e Ta rg et s Ye ar Re sp on si bi lit y Co lla bo ra tin g pa rt ne rs Es tim at ed Co st (N u in m ill io n) 1 2 3 4 5 6. 1 Im pl em en t t he In pa tie nt fo od se rv ic e gu id el in es 2 01 9 tr an s- la tin g it in to lo ca l c on te xt . • D ev el op a nd im pl em en t TO R fo r F SS s ta ff (C ap ac ity b ui ld in g of fo od s er - vi ce s to re in -c ha rg es a nd c oo ks . Fo od s er vi ce in fr as tr uc tu re , Pr op or tio n of h ea lth fa - ci lit ie s im pl em en tin g th e gu id el in e 0 10 0% X X X X X N P D M S an d D O PH , D H O s, CM O s 6. 0 6. 2 D ev el op a nd im pl em en t e ss en - tia l n ut rit io n an d di et et ic s ca re pa ck ag e Pr op or tio n of h ea lth fa ci lit ie s w ith n ut rit io n pr of es si on al s im pl em en t- in g th e pa ck ag e 0 >9 5% X X X X N P N P, N ut ri- tio ni st s an d re le va nt sp ec ia lis ts 1. 5 6. 3 St an da rd iz e an d im pl em en t sc re en in g an d as se ss m en t p ro - to co ls fo r c lin ic al n ut rit io ni st s/ di et iti an s. Pr op or tio n of h ea lth fa ci l- iti es w ith n ut rit io n pr of es - si on al s im pl em en tin g th e st an da rd iz ed p ro to co ls . 0 10 0% X X X X N P N P, N ut ri- tio ni st s 0. 7 6. 4 En ha nc e th e ca pa ci ty o f n u- tr iti on p ro fe ss io na ls to d el iv er en te ra l a nd p ar en te ra l n ut rit io n fo r c rit ic al ly il l p at ie nt s. • D ev el op a nd s ca le u p im pl em en ta tio n of p ar en - te ra l a nd e nt er al n ut rit io n gu id el in es . Pr op or tio n of h ea lth fa ci lit ie s w ith n ut rit io n pr of es si on al s im pl em en t- in g en te ra l a nd p ar en te ra l nu tr iti on >9 0% X X X N P D H S an d de ve l- op m en t pa rt ne rs 2. 5 6. 5 D ev el op a nd p ro m ot e nu tr iti on sc re en in g, a ss es sm en t a nd tr ia ge to a ll in di vi du al s se ek in g he al th ca re Pr op or tio n of h ea lth fa ci lit ie s w ith n ut rit io n pr of es si on al s im pl em en t- in g th e pr ot oc ol 10 0% X X X N P / D H S D ev el - op m en t pa rt ne rs 1. 5 6. 6 D ev el op a nd im pl em en t c om m u- ni ty in iti at iv es to p re ve nt /r ed uc e nu tr iti on re la te d he al th is su es . N o of in iti at iv es in iti at ed 0 5 X X X X N P N ut rit io ni st 4. 0 6. 7 D ev el op a nd im pl em en t N u- tr iti on E du ca tio n pa ck ag e fo r H ea lth w or ke rs Pr op or tio n of h ea lth w or ke rs w ith n ut rit io n ed uc at io n 0 >9 5% X X X X N P D H S, H ea lth w or ke rs 10 6. 8 Pr om ot e co nt in ue d pr of es si on - al d ev el op m en t a nd im pr ov e co or di na tio n am on g nu tr iti on pr of es si on al s. N o of C M Es c on du ct ed 0 5 X X X X X N P N ut rit io ni st 4. 0 73 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 74 SR A 7: S tr en gt he ni ng g ov er na nc e an d pa rt ne rs hi ps in s up po rt o f n ut rit io n in te rv en tio ns Ac tio n Pl an s O ut pu t i nd ic at or s Ba se lin e Ta rg et s Ye ar Re sp on si bi lit y Co lla bo ra tin g pa rt ne rs Es tim at ed Co st (N u in m ill io n) 1 2 3 4 5 7. 1 Es ta bl is h a N at io na l N ut rit io n Ta sk F or ce to g ui de th e im pl e- m en ta tio n of n ut rit io n ac tio ns ac ro ss a ll re le va nt s ec to rs N at io na l N ut rit io n Ta sk F or ce e st ab - lis he d 0 M ul tia ge nc y ta sk fo rc e te am X N P Al l r el ev an t se ct or s 0. 5 7. 2 Co nd uc t N at io na l N ut rit io n Ta sk F or ce c oo rd in at io n m ee t- in g ev er y si x m on th s N o of N at io na l N ut rit io n Ta sk F or ce m ee tin gs c on du ct ed 0 7 X X X X N P Al l r el ev an t se ct or s 5. 0 7. 3 St re ng th en e m er ge nc y pr e- pa re dn es s an d re sp on se ca pa ci ty o f d is tr ic t e m er ge nc y nu tr iti on c oo rd in at or s Pr op or tio n of di st ric ts w ith tr ai ne d co or di na to rs N A 10 0% X X X X N P D is tr ic t nu tr iti on c o- or di na to rs 1. 5 75 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) SR A 8: M on ito rin g an d ev al ua tin g nu tr iti on s ec ur ity s itu at io n an d re la te d in te rv en tio ns Ac tio n Pl an s O ut pu t i nd ic at or s Ba se lin e Ta rg et s Ye ar Re sp on si bi lit y Co lla bo ra tin g pa rt ne rs Es tim at ed Co st (N u in m ill io n) 1 2 3 4 5 8. 1 Ev al ua te th e su st en an ce o f Io di ne D efi ci en cy D is or de r St at us . N o. o f e va lu at io ns co nd uc te d N A 1 X X N P W H O U N IC EF 4. 0 8. 2 Co nd uc t n at io na l l ev el n u- tr iti on s ur ve y to a ss es s th e nu tr iti on s itu at io n an d gi ve ev id en ce fo r e va lu at io n an d nu tr iti on p ro gr am m in g N o of s ur ve ys c on - du ct ed N A 1 X X X N P Al l r el ev an t se ct or s 50 8. 3 Ex pl or e th e im pl em en ta tio n of na tio na l m ic ro nu tr ie nt s ur ve y N o of s ur ve ys c on - du ct ed N A 1 X X X N P Al l r el ev an t se ct or s 80 8. 4 Re vi ew a nd re vi se th e nu - tr iti on in fo rm at io n sy st em fo r q ua lit y m on ito rin g an d im pl em en ta tio n of n ut rit io n ac tiv iti es b y th e fie ld w or ke rs Re vi si on o f N IS in th e H M IS N A Re vi si on of N IS co nd uc te d X X X X X N P H M IS , P PD U N IC EF 5 8. 5 Im pl em en t n ee d- ba se d as se ss m en t/ s tu dy to in fo rm po lic y, pr og ra m d es ig n an d im pl em en ta tio n N o. o f a ss es sm en ts / st ud ie s co nd uc te d N A N A X X X X X N P H M IS , P PD U N IC EF 20 8. 6 St re ng th en re se ar ch c ap ac ity in th e fie ld o f n ut rit io n N o of c ap ac ity b ui ld in g tr ai ni ng s co nd uc te d N A 2 X X X N P D ev el - op m en t pa rt ne rs 5. 0 NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 76 77 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) ANNEXURE List of contributors Sl. No. Name Designation Agency 1 Sangay Phuntsho Sr. Program Officer DoPH, MoH 2 Choney Dema Assistant Program Officer DMS, MoH 3 Karma Tenzin Program Officer DoPH,MoH 4 Wangdi Gyeltshen Chief Program Officer DoPH,MoH 5 Pemba Yangchen Dy.Chief Program Officer DoPH,MoH 6 Chimmi Dem Sr.Program Officer DoPH, MoH 7 Hari Prasad Pokhrel Sr.Nutritionist Gidakom Hospital 8 Passang Lhamo Assistant Professor FNPH 9 Dr. Phillip Erbele Assistant Professor/Pediatrician FNPH 10 Dr. Indrani Chakma Health & Nutrition Specialist UNICEF 11 Thukten Penjor Sr.Nutritionist JDWNRH 12 Laigden Dzed Dy.Chief Program Officer NCDD, MoH 13 Loday Zangpo Sr.Program Officer NCDD, MoH 14 Tshewang Lhadon Assistant Program Officer LSRD, MoH 15 Dr. Chandra Lal Mongar Health & Nutrition Officer UNICEF 16 Watanabe Kozo Chief Representative JICA 17 Manasi Shukla Consultant (food tech) WFP 18 Gyem Bidha Dy. Chief Regulatory Quality Officer BAFRA 19 Tshering Penjor Marketing Officer DAMC, MoAF 20 Wangda Dukpa Chief Agriculture Officer DoA, MoAF 21 Sonam Choden Dy. Chief Program Officer DoFPS, MoAF 22 Ganga Maya Rizal Dy. Chief FFO DoL, MoAF 23 BB Rai Head SAP SAP, DoA 24 Ryo Namiki Volunteer Coordinator JICA 25 Tashi Yangzom Dy. Chief Planning Officer PPD, MoAF 26 Kinley Wangmo Information Media Officer PMO 27 Tobgay C4D Specialist UNICEF 28 Kencho Wangdi National Professional Officer WHO 29 Kuenzang Deki Nutritionist MoE 30 Kencho Wangmo NPO WFP 31 Namgay Thinley Chief Agriculture Officer MoAF 32 Choney Zangmo Dy Chief Horticulture Officer MoAF NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 78 33 Rinchen Wangmo Sr. Agriculture Officer MoAF 34 Sherab Dorji Sr. Planning Officer MoAF 35 Yeshi Jamtsho Sr. Program Officer OCP, MoEA 36 Rinchen Lhazom Offing.DG DoT, MoEA 37 Pema Khandu Sr. TO DoT, MoEA 38 Nidup Tshering Sr.TO DoT, MoEA 39 Lobzang TO DoT, MoEA 40 Sonam T Dorji Chief Trade Officer DoT, MoEA 41 Dr.Tulsi Ram Sharma Pediatrician JDWNRH 42 Namgay Thinley Chief Agriculture Production Officer MoAF 43 Choney Zangmo Dy. Chief Horticulture Officer MoAF 44 Rinchen Wangmo Sr. Agriculture Officer MoAF 45 Sherab Dorji Sr. Planning Officer MoAF 46 Kinley Wangchuk Sr. Program Officer DoPH, MoH 47 Dechen Yangden Chief Engineer MoWHS 48 Thinley Choden Principal Engineer MoWHS 49 Kubir Nath Bhattarai Dy. CRQO BAFRA 50 Vishal Chhetri DCLO RCDC 79 | NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) TERMS OF REFERENCE (TOR) FOR NNTF 1. Membership to the NNTF is based on official position and will be automatically transferred to the person assuming the position when an incumbent member is transferred. 2. The National Nutrition Task Force will meet every six months to review the implementation of nutrition related activities in the country. 3. The Nutrition program will inform the task force members at-least one week in advance regarding the meeting. 4. At least one-third of the members must be present for a sitting. 5. The task force may call for alternate members as required by the agenda from time to time. 6. The NNTF members will provide guidance to their respective agencies to discuss and push forward the nutrition agenda. 7. A detailed term of reference and responsibilities for each member will be discussed and finalized during the first sitting after the formation of the task force. Director, DoPH (Chairperson) • Provide directives and guidance to the NNTF. Pediatrician (Technical Adviser) • Provide technical guidance to the NNTF. Chief Program Officer, School Health and Nutrition Division, Department of School Education, Ministry of Education • Provide guidance to the Ministry of Education and school feeding program in particular. • Act as a bridge between DSE, MoE and NNTF Chief Agriculture Officer, Agriculture Production Division, Department of Agriculture, Ministry of Agriculture and Forests • Provide technical backstopping to the NNTF on agricultural and bio- fortification and food fortification efforts in Bhutan. • Act as a bridge between NNTF and DoA, MoAF. NATIONAL NUTRITION STRATEGY AND ACTION PLAN (2021-2025) | 80 Chief Livestock Officer, Livestock Production Division, Department of Livestock, Ministry of Agriculture and Forests • Provide technical backstopping to the NNTF on livestock produce and ways to enhance nutrition and production. • Act as a bridge between NNTF and DoL, MoAF. Chief Engineer, Water and Sanitation Division, Department of Engineering, Ministry of Works and Human Settlement • Promote and strengthen Water, Sanitation and Hygiene (WASH) as a part of infrastructure development in the country. • Act as a bridge between NNTF and DoE, MoWHS. Head, Food and Nutrition Laboratory, Royal Centre for Disease Control • Provide technical backstoppings and reference laboratory for all nutrition activities requiring laboratory testing. Representatives from development partners and non-governmental organization • Provide technical and financial assistance to conduct nutrition related activities. Other members to be co-opted as and when required • The task force may call for alternate members / experts from time to time as required by the agenda. Nutrition Program, DoPH, MoH (Secretariat to the NNTF) • Convene NNTF meeting. • Update the NNTF on nutrition situation in the country. • Keep records of all the meetings, decisions made and follow up on the implementation of nutrition activities in the country. Designed and Printed at Bhutan Printing Solutions (www.prints.bt) Cover Final Inside Pages