National Nutrition Policy (2021-2025)

THE REPUBLIC OF THE GAMBIA NATIONAL NUTRITION POLICY (2021 – 2025) The Gambia Free of Malnutrition 2021 FOOD CARE NUTRITION SECURITY EDUCATION ENVIRONMENT COMMUNITTY EMPOWERMENT ECONOMIC EMPOWERMENT HEALTH 1 Table of Contents Country Profile ................................................................................................................................................... 2 Justification .................................................................................................................................................... 2 Priority Areas and Implementation Strategies ............................................................................................... 3 Vision ............................................................................................................................................................. 3 Goal ................................................................................................................................................................ 3 2. Promoting Optimal Infant and Young Child Feeding .................................................................................... 6 3 Food and Nutrition Security at National, Community and Household Levels ........................................... 8 4. Preventing Micronutrient Deficiencies ........................................................................................................ 10 5: Improving Food Standards, Quality and Safety ........................................................................................... 12 6. Nutrition and Infectious Diseases ................................................................................................................ 14 7. Nutrition and HIV/AIDS .............................................................................................................................. 16 8. Preventing and Managing Diet-Related Non-Communicable Diseases ................................................... 17 9. Caring for the Socio-Economically Deprived and Nutritionally Vulnerable .............................................. 19 10. Nutrition in Emergencies ........................................................................................................................... 20 11. Nutrition Surveillance ................................................................................................................................ 22 12. Nutrition Research ..................................................................................................................................... 23 13. Social and Behaviour Change Communication (SBCC) ........................................................................... 24 14. Resource Mobilisation ............................................................................................................................... 26 15. Mainstreaming Nutrition into Development Policies, Programmes and Legislations ............................... 28 16. Policy Implementation Framework ............................................................................................................ 29 17. Human Resources for Effective Policy Implementation ............................................................................ 42 18. Monitoring and Evaluation ........................................................................................................................ 43 2 Country Profile The Gambia is in West Africa and occupies an area of 11, 365 square kilometres. It is a small subtropical country bordered to the north, south, and east by Senegal and has an 80 kilometres coast to the west. The 2013 Census puts the country’s population at approximately 1.86 million people, with an annual growth rate of 3.1 percent (between 2003 and 2013). The country has one of the highest population densities: 173 persons per square kilometre. The urban population has grown significantly due to an upsurge in rural-urban migration and immigration. A high dependency ratio (202 per 100 employed persons) puts a growing demand and strain on household income, the food budget, and social services. Fertility rate stands at 4.4 children per woman (DHS, 2019-20). Literacy stands at 63 percent among the age group of 15 years and over (2013 Census). The country’s economy is predominantly agrarian with crop production, livestock rearing and fishing being the major activities. Services are emerging as a significant contributor to the economy. Tourism is the second largest employer and revenue generating source for the country, contributing 12 – 15 percent of gross domestic product (GDP). Industries are very limited and mainly light. The 2020 Human Development Index ranked The Gambia 172 out of 189 countries, making it one of the world’s poorest and least developed countries. Justification Investing in nutrition is judicious and beneficial as it improves physical work capacity, cognitive development, school performance, and health, by reducing morbidity and mortality, which in turn, leads to increased productivity, socio-economic growth and development, and poverty reduction. The Government of The Gambia’s recognition and acknowledgement of the crucial and central role nutrition plays in a nation’s socio-economic growth and development led it to formulate and adopt a National Nutrition Policy (NNP) in 2000, covering a four-year period. At its expiration, a new one was articulated to continue the quest to improve the nutritional status of the population over the next 10 years, 2010 to 2020, which included new nutrition and nutrition-related issues that had emerged in the preceding years. The current policy has reached the end of its’ life span and the strategic plan that accompanies its implementation had expired, coupled with the global shift from the Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs) necessitates the review and development of a new policy. This comprehensive National Nutrition Policy 2021-2025, complemented by a costed Strategic and Business Plans to enable its implementation over the designated period, should assure significant improvements in the nutritional status of The Gambia’s population, and contribute to the country’s realization of the United Nation’s SDGs (2016 – 2030) and the National Development Plan (NDP, 2018 - 2021). It will also support the fulfilment of the government’s commitment to protect the fundamental human rights of the Gambians outlined in the 1997 Constitution of The Republic of The Gambia, Universal Declarations on the Eradication of Hunger and Malnutrition (1974), the 1948 Universal Declaration of Human Rights, African Charter on Human and Peoples' Rights, UN Convention on the Rights of the Child (CRC, 1990) and the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW - 1979). 3 Priority Areas and Implementation Strategies The new National Nutrition Policy’s focus will be on the following priority areas: 1. Improving maternal nutrition; 2. Promoting optimal infant and young child feeding; 3. Improving food and nutrition security at the national, community and household levels; 4. Preventing and managing micronutrient deficiencies; 5. Improving food standards, quality and safety; 6. Nutrition and infectious diseases; 7. Nutrition and HIV/AIDS; 8. Preventing and managing diet-related Non-Communicable Diseases; 9. Caring for the socio-economically deprived and nutritionally vulnerable; 10. Nutrition in emergencies and; 11. Nutrition surveillance. The implementation of these priority areas will be through: 1. Community Nutrition Programming; 2. Social and Behaviour Change Communication; 3. Resource mobilisation 4. Mainstreaming nutrition into development policies, legislations, strategies and programmes; 5. A structured Policy Implementation Framework; 6. Effective monitoring and evaluation and 7. Nutrition research. MISSION STATEMENT The overall mission of the National Nutrition Agency (NaNA) is to improve the nutritional status thus reducing malnutrition, morbidity and mortality among the general population, especially the most vulnerable groups; pregnant and lactating women and children under five years of age, thereby contributing to the productivity of The Gambian population and the socio-economic development of the country and to transform the Agency into a viable and sustainable Centre of Excellence in the area of nutrition policy formulation, research, capacity building, public health nutrition planning and programming in the region of Africa. This will contribute immensely towards the realisation of the Millennium Development Goals (MDGs) and Vision 2020, to which the Government of The Gambia is fully committed. This mission can be realised by working with all stakeholders including communities and community based organisations involved in nutrition and nutrition related areas, mainstreaming nutrition into other sector policies, programmes and strategies and better coordination of nutrition interventions in the country. Information, education and communication (IEC) and behaviour change communication (BCC) will play a major role towards achieving this mission. Vision A malnutrition free Gambia that assures a healthy and sustainable living for all. Goal To improve The Gambian population’s nutritional status especially that of the most vulnerable groups. 4 1: Improving Maternal Nutrition Preamble Good nutritional status is essential for the health, productivity and survival of every individual throughout the life cycle. The body’s ability to function normally is impaired when there is insufficient energy and nutrient supply. In The Gambia, malnutrition still continues to be a major public health problem with the most vulnerable groups being women and children. It is evident that the majority of Gambian women, especially those living in rural areas are in a constant state of energy deficit due to poor dietary habits, heavy workload and frequent infections. According to the Demographic Health Survey (DHS, 2019-20), 13.6% of non pregnant women of child bearing ages were underweight, while 22.2% and 14.2% were overweight and obese, respectively. While underweight had improved from 16.7%, overweight and obesity increased from 15.3% and 7.3% respectively (DHS, 2013). Amongst pregnant women, 7.5% were reported to be wasted. The DHS (2019-20) also reported that 44.3% of women 15 – 49 years were anaemic (54.8% for pregnant women, 46.6% for breastfeeding mothers and 42.4% for non-pregnant, non-lactating women) down from 60.3% in 2013. This is an indication that both under-nutrition and over-nutrition as well as micronutrient deficiency are prevalent amongst women. The Maternal Mortality Ratio has improved over the years but it still remains unacceptably high at 289 per 100,000 live births (DHS, 2019-20) down from 433/100,000 livebirths in 2013. Low birth weight (LBW) is also reported to be 11.0% (DHS, 2019-20) down from 12% (DHS, 2013). The proportion of women 15 – 49 years Literate is reported to be 48.1% and this is much less that their male counterparts (63.4%) who are within the same age range (MICS, 2018). Women who are of short stature are at a greater risk of developing obstetric complications due to their smaller pelvic sizes. Also, women who are wasted are at a greater risk of delivering LBW babies, which leads to the intergenerational effect of malnutrition, as LBW babies are likely to become small as adults. Addressing maternal nutrition requires the life cycle approach since the problem tends to start in utero and continues into infancy, childhood, adulthood and old age. Over the years, efforts instituted to address maternal malnutrition in The Gambia include training of health workers on basic nutrition using the life cycle approach, promotion of dietary diversification, with the support to establishing communal or backyard gardens, iron/folate supplementation of pregnant women, the provision of labour-saving devices, Targeted Supplementary Feeding of pregnant women and the promotion of optimal infant and young child feeding practices. Goal 1.0 To improve the nutritional status of women before, during and after pregnancy. Objectives 1.1 To reduce the prevalence of malnutrition among women of child bearing ages. 1.2 To reduce the prevalence of micronutrient malnutrition among women of child bearing ages. Strategies 1.1.1 Support capacity building of stakeholders on the prevention and control of malnutrition. 1.1.2 Strengthen inter and intra-sectoral collaboration on the prevention and control of maternal malnutrition, 1.1.3 Support the intensification of SBCC on the causes, consequences, prevention and control of adolescent and maternal malnutrition. 1.1.4 Advocate for the provision of labour and time saving devices. 1.1.5 Advocate for the enrolment and retention of the girl child including adolescents in school. 1.1.6 Strengthen and expand the Baby Friendly Hospital Initiative (BFHI) and Baby Friendly Community Initiative (BFCI) Programmes. 5 1.1.7 Advocate for the enforcement of the Women’s Act, 2010 and the implementation of the Gender and Women’s Empowerment Policy 2010-2020. 1.1.8 Promote the adherence to the Maternity Care Guidelines. 1.1.9 Support adult literacy and related programmes. 1.2.1 Strengthen Micronutrient Supplementation especially iron/folate supplementation of adolescent girls, pregnant and lactating women. 1.2.2 Advocate for the enforcement of the Food Fortification Regulation 2020. 1.2.3 Expand and strengthen the Integrated Community-based Anaemia Control Programme. Targets 1. Percentage of underweight amongst women 15– 49 years reduced by 40% from 15.4% (2019-20) to 10.6% by 2025. 2. Percentage of obesity amongst women 15-49 years reduced by 40% from 11.1% (2018) to 5.5% by 2025. 3. Prevalence of anaemia in women 15 reduced from 68% (2013) to 35% by 2025. 6 2. Promoting Optimal Infant and Young Child Feeding Preamble Sound nutrition is the foundation for child survival, growth and development. Good nutrition is recognized by the Convention on the Rights of the Child as one of the child rights for the enjoyment of the highest attainable standard of health. Good nutrition, especially in the first 1,000 days (from conception to two years of age) of a child’s life, also offers massive returns in health, education and productivity. In the first fragile years of life, under-nutrition affects a child’s physical and cognitive development. An undernourished girl child may well become an undernourished mother, risking foetal brain damage, low birth-weight and neonatal death, thus resulting in a cycle of perpetual malnutrition. Infants and young children have high nutritional requirements relative to their body sizes because of their rapid growth and development. Adequate nutrition is essential for the infant and young child to reach their full growth potential. Optimal feeding practices of children 0 to 24 months are critical in breaking the cycle of malnutrition. Breastmilk is the ideal food for optimal infant growth and development. Breastfeeding is beneficial to both maternal and infant health. However, the full benefits of breastfeeding can only be realised if optimal infant and young child feeding is practised. Early initiation of breastfeeding and exclusive breastfeeding for the first six months of life followed by the introduction of an age appropriate complementary feeding and continued breastfeeding up to 2 years and beyond will prevent childhood malnutrition and eventually reducing childhood morbidity and mortality. Over the years, the prevalence of malnutrition amongst children has improved. According to DHS (2019-20), stunting among children under-five years was 17.5%, wasting was 5.1% and underweight was 11.6%. These are down from 24.5%, 11.5% and 16.2%, respectively in (DHS 2013). A pooled analysis of 10 prospective studies from Africa, Asia and Latin America found that children under 5 years that are malnourished are at a greater risk of dying1. According to WHO, malnutrition contributes to over 50% of underfive mortality (WHO, 2000). The Cost of Hunger in Africa study in The Gambia (2018) has shown that malnutrition has serious implications for health, education and the labour force. The study found that the country lost about GMD3.96 billion (US$83.4 million) in 2018 due to malnutrition and this is equivalent to 5.1% of The Gambia’s GDP. Sub-optimal infant and young child feeding is common in The Gambia. According to DHS (2019-20), almost all children in The Gambia have ever been breastfed (98%), only 36% are breastfed within an hour of birth and 53.6% are exclusively breastfed. The low prevalence of exclusive breastfeeding may be due to cultural, economic, social and political factors. In addition, among breastfed children 6 to 23 months, 91.8% were introduced to complementary foods, 20.6% received the minimum dietary diversity, 51.1% had the minimum meal frequency and 15.0% received the minimum acceptable diet. (DHS, 2019-20). Although the prevalence of HIV is low in The Gambia as shown in the results from the HIV Sentinel Surveillance (2018), (1.5% of pregnant women are HIV Positive), optimal infant and young child feeding is still beneficial to the child. In order to address optimal infant and young child feeding adequately, the country adopted the WHO/UNICEF Global Strategy for Infant and Young Child Feeding (IYCF). The following programmes are being implemented to ensure optimal IYCF: Baby Friendly Hospital Initiative (BFHI), Baby Friendly Community Initiative (BFCI), Prevention of Mother to Child Transmission (PMTCT) of HIV, Social and Behavioural Change Communication (SBCC), Integrated Management of Acute Malnutrition (IMAM) and other capacity building interventions. Goal 2.0 To improve the nutritional and health status of infants and young children. 1Olofin I, et al (2013). Associations of suboptimal growth with all-cause and cause-specific mortality in children under five years: a pooled analysis of ten prospective studies. PLoS One 8 (5): e64636. 7 Objectives 2.1 To promote optimal infant and young child feeding practices. 2.2 To create an enabling environment for mothers and care givers to make and implement informed feeding choices. 2.3 To raise public awareness on the main problems affecting infant and young child feeding. 2.4 To treat and control acute malnutrition in underfive children. Strategies 2.1.1 Promote the use of safe and nutritious locally available complementary foods. 2.1.2 Increase awareness of legislators, policy makers, councillors and the public on the importance of optimal infant and young child feeding. 2.1.3 Support the implementation of community-based programmes, which promote, protect and support optimal infant and young child feeding practices. 2.1.4 Strengthen the enforcement of the Breastfeeding Promotion Regulation 2006. 2.2.1 Advocate for the provision of an enabling environment to facilitate breastfeeding at workplaces. 2.2.2 Strengthen and expand the BFHI) and BFCI Programme. 2.2.3 Improve capacity of health care providers, community-based extension workers and community representatives on infant and young child feeding. 2.2.4 Advocate for the incorporation of infant and young child feeding into the curricula at all levels of the formal, non-formal and Madrassa education system including the health training institutions. 2.2.5 Strengthen monitoring systems to effectively track progress of infant and young child feeding trends. 2.2.6 Promote the implementation of Early Childhood Development interventions that stimulate and encourage responsive feeding. 2.2.7 Advocate for automatic inclusion of Early Childhood Development Centres in Public Schools with School Feeding Programme. 2.3.1 Advocate for the mainstreaming of infant and young child feeding issues into other relevant sectoral policies and plans. 2.3.2 Support interventions that promote improved water, hygiene and sanitation practices. 2.4.1 Strengthen and scale-up the implementation of all the components of the Integrated Management of Acute Malnutrition (IMAM) Protocol. 2.4.2 Strengthen growth monitoring and promotion at community and health facility level. Targets 1. Percentage of children under five years of age who are stunted reduced from 24.5% in 2013 to 14.7% by 2025 2. Percentage of children under five years of age who are underweight reduced from 16.2% in 2013 to 9.7% by 2025 3. Percentage of children under five years of age who are wasted reduced from 11.5% in 2013 to less than 5% by 2025. 4. Percentage of children under five years of age who are overweight maintained below 5% by 2025 5. Increase Exclusive Breast feeding rate from 47% in 2013 to 60% by 2025. 8 3 Food and Nutrition Security at National, Community and Household Levels Preamble Food security exists when all people, at all times, have access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life. Nutrition security is achieved for a household when secure access to food is coupled with a sanitary environment, adequate health services, and knowledgeable care and support to ensure a healthy life for all household members. Households in The Gambia experience both acute and chronic food insecurity. The Gambia is classified as a low-income food deficit country by FAO which produces only about 50% of the total national food consumption needs. The 2016 Comprehensive Food Security and Vulnerability Analysis (CFSVA) revealed that at the national level about 8% of the total population is food insecure or vulnerable to severe food insecurity during normal times. According to the Integrated Household Survey (IHS, 2016) 55.1% of the population is food insecure, and 35.9% of the population would not meet their daily food requirements of 2400 kcals even if they allocated all their consumptions to food. Despite the relative increasing trend of cereal net production, the country’s cereal needs has been consistently above local production due to high population growth. Since 1991, the national population has increased by half a million with a corresponding increase also in food requirement. However, agricultural production has been contracting due to climate change related phenomenon (erratic rainfall and early cessation of rainfall). Achieving the nutrition-related goals of the SDGs, Agenda 2063 and NDP (2018 - 2021) requires that national and sectoral development policies and programmes are complemented by effective community-based actions aimed at improving household food and nutrition security. It would also require the promotion of the consumption of local dishes made from locally produced food nationally including in hotels to boost the tourism sector. Over the years, several programmes have been implemented to address food and nutrition insecurity such as supporting households and communities to establish gardens, technological transfers, capacity building, social safety nets and value chain addition of agricultural products including livestock, poultry and fisheries. Goal 3.0 To achieve food security, improved nutrition and promote sustainable agriculture. Objectives 3.1 To promote the utilization of diverse and safe foods of high nutritional value. 3.2 To advocate for the adoption of agricultural value chain development approach. Strategies 3.1.1 Support the improvement of access by all people, particularly vulnerable people, to safe, nutritious and sufficient food all year round. 3.1.2 Support SBCC interventions on food and nutrition security, 3.1.3 Promote optimal infant and young child feeding practices, 3.1.4 Promote multi-stakeholder collaboration in addressing food and nutrition security issues, 3.1.5 Advocate for the construction of a Food Balance Sheet for The Gambia. 3.2.1 Advocate for the availability, affordability and accessibility of food including animal sources countrywide. 3.2.2 Support implementation of food-based dietary interventions focusing on local production, processing, preservation and utilisation at community level. 9 3.2.3 Advocate for the provision of adequate infrastructure for production, processing, storage, marketing and distribution of food commodities. 3.2.4 Support self-sustaining producer groups or associations at community level in production, processing, packaging and marketing. 3.2.5 Advocate for the strengthening of national capacity to assess, analyze, monitor and evaluate food and nutrition security situations in a timely manner. 3.2.6 Support the food rights advocacy groups. 3.2.7 Support and promote the implementation of sustainable and resilient (climate smart) agricultural practices including aquaculture. 3.2.8 Promote the consumption of diversified local dishes in the hospitality industry. 3.2.9 Support small and medium enterprise food processors 3.2.10 Advocate for good food production, processing, storage, distribution, marketing and consumption practices to reduce mycotoxins in particular aflatoxin contamination. Targets 1. Prevalence of food insecurity reduced from 8% in 2016 to 5% by 2025 2. Proportion of households with high dietary diversity scores increased from 64.2% to 80% by 2025 10 4. Preventing Micronutrient Deficiencies Preamble Micronutrients are vitamins and minerals needed by the human body in small quantities for proper growth, development and wellbeing. In The Gambia, micronutrient deficiencies of public health importance are Iodine Deficiency Disorders (IDD), Vitamin A Deficiency (VAD) and Iron Deficiency Anaemia (IDA) among others. The main causes are inadequate intake of foods rich in these micronutrients and their impaired absorption and/or utilization. Poor absorption of micronutrients can be caused by the consumption of inhibitors as well as intestinal parasites, malaria, diarrhoea and other infections which deplete the micronutrient reserves. Micronutrient deficiencies are responsible for a number of serious health issues including compromised immune systems, metabolic disorders and delayed or impaired physical growth and mental development. Morbidity and mortality due to micronutrient deficiencies are greatest in those who are least advantaged i.e. the vulnerable groups such as women and under-five children. The country has made significant strides in addressing micronutrient deficiencies, however, there still remains challenges. The 2019-20 DHS estimated that 77% of households consume iodised salt, 44.8% of the children suffered from some form of anaemia with 1.1% being severely anaemic. These have improved compared DHS 2013 where 72.8% had some form of anaemia and 4.0% had severe anaemia. The prevalence of anaemia was higher among children in rural areas (59.5 %) compared to urban areas (37.1%). According to The Gambia Micronutrient Survey (GMNS, 2018), the prevalence of Vitamin A Deficiency amongst children under 5 years is 18.3%. Vitamin A Supplementation coverage for children 6 – 59 months has declined from 68.7% (DHS, 2013) to 57.4% (DHS, 2019-20) but coverage for deworming increased from 33.9% (DHS, 2013) of children 12 - 595 months to 39.4% (DHS, 2019-20). The Gambia is committed to resolutions of the World Summit for Children (September, 1990), the Dakar Consensus Conference (October, 2004) and numerous other resolutions to reduce, prevent or eliminate micronutrient deficiency disorders. Multiple interventions to address micronutrient deficiencies are required to reduce human suffering and economic losses. Such interventions include: dietary diversification which are long term and sustainable ways of addressing micronutrient deficiencies. Various interventions to combat micronutrient deficiencies are being implemented. These include vitamin and mineral supplementation, food fortification and bio-fortification, promotion of the consumption of micronutrient rich foods, deworming, promotion of the use of iodized salt and SBCC. Regulations have been promulgated to support the prevention and control of micronutrient deficiencies such as the Food Fortification Regulation (2020). Despite these interventions, the prevention and management of micronutrient deficiencies is still a challenge. Hence, the need for strengthening the existing interventions as well as the prevention and control of emerging micronutrient deficiencies such as zinc and selenium. Goal 4.0 To prevent and control micronutrient deficiencies among the population especially adolescents, women and children under-five. Objectives 4.1 To increase awareness on micronutrient deficiencies in the general population. 4.2 To increase household consumption of micronutrient rich foods. 4.3 To reduce the prevalence of diseases related to micronutrient deficiencies among the general population especially women and children. 11 Strategies 4.1.1 Promote behavioural change communication for collective action to improve knowledge, attitude and practices on micronutrient deficiencies. 4.1.3 Promote nutrition sensitive programing in the education system. 4.2.1 Promote the production, processing, preservation and consumption of foods rich in micronutrients. 4.2.2 Support the enforcement of the Food Fortification Regulation 2020. 4.2.3 Advocate for using schools as centres for the multiplication of bio-fortified food crops 4.3.1 Strengthen collaboration and linkages with stakeholders in the food system. 4.3.2 Strengthen micronutrient supplementation programmes at all levels specifically for the identified vulnerable groups. 4.3.3 Strengthen micronutrient interventions with other public health measures such as Expanded Programme on Immunization (EPI) / Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) services, malaria programs and Water, Sanitation and Hygiene (WASH). 4.3.4 Promote home fortification through the use of Multiple Micronutrient Powders (MMP) in improving complementary foods for children under the age of 2 years. 4.3.5 Strengthen the National Micronutrient Coordination Bodies. 4.3.6 Advocate for the sustainable implementation of Food Fortification and Bio-fortification programmes. 4.3.7 Support the functioning of the National Alliance for Food Fortification (NAFF). Targets 1. Proportion of households consuming adequately iodised salt increased from 76% in 2013 to 90% by 2025. 2. Prevalence of vitamin A deficiency in children under five reduced from 64% (1999) to 20% by 2025. 3. Proportion of children aged 6- 59 months supplemented with a high dose of vitamin A in the past six months increased from 68.7% in 2013 to 80% by 2025. 4. Prevalence of anaemia in women of child bearing ages reduced from 68% (2013) to 35% by 2025. 5. Proportion of children 12 – 59 months who received deworming tablet in the last 6 months increased from 34% (2013) to 75% by 2025. 12 5: Improving Food Standards, Quality and Safety Preamble Safe and adequate food supply is not only essential for proper nutrition but also for trade. An effective food control system throughout the food chain is necessary for improved nutritional wellbeing. To support nutrition improvement, an integrated control of the whole food chain must assure that procedures for producing, preparing, storing, distributing and consuming food is hygienic with little or no contamination. Research has shown that contaminated complementary foods account for a substantial proportion of diarrhoeal diseases in infants and young children due largely to unsafe and unhygienic food. The quality and safety of most foods prepared for and consumed by the public in The Gambia, especially, complementary foods, street foods, fast foods and perishable foods, though improving, leaves much to be desired. The situation can largely be attributed to the limited knowledge, awareness and behaviour of producers, processors, food handlers and consumers on the role of food standards for good health and improved nutritional status. Over the years there has not been major food poisoning outbreaks, but there were sporadic cases reported. As a result of increasing concern on food safety that has become widely recognized, the public sector has responded with the formulation and enactment of the Food Safety and Quality Act 2011, which established the Food Safety and Quality Authority to ensure that foods produced, manufactured, sold, distributed, imported and exported are safe and of high quality. The enactment of the Food Safety and Quality Act, 2011 aims to control the conditions of production, transport and sale, to eliminate or minimise as far as is reasonably practicable, the occurrence of known or potential hazards to the health of the consumer. The Act established structures such as the Board of Directors, Food Control Advisory Board, the Authority, Scientific Committee and Stakeholders Consultative Forum to support its smooth implementation. However, there is need for the continuous coordination and support of these structures and the implementation of the provisions of the Act to ensure safety, quality and standards. Another Agency established is The Gambia Standards Bureau (TGSB) which has the responsibility of setting food safety and quality standards. Over the years, a reasonable number of food standards have been gazetted, which seeks to compliment the food control system. In the same vein, the Food Fortification Regulation was enacted in 2020. Goal 5.0 To contribute to the assurance of a safe and quality Food Control System in The Gambia. Objectives 5.1 To contribute towards ensuring that food produced and/or consumed by the Gambian population is safe and of high nutritional value. 5.2 To raise public awareness on the importance of quality and safe food to nutrition. Strategies 5.1.1 Support the development of standards and technical regulations on foods. 5.1.2 Support the review, update and/or formulation of legislations, guidelines, standards and code of practices on food and nutrition. 5.1.3 Promote regional and international cooperation in the area of food standard and safety. 5.1.4 Support research to provide a robust evidence base for health and nutrition improvement. 13 5.1.5 Strengthen the public private partnership in Food Safety, Quality and Standards (Work in partnership with government and stakeholders in improving the nutritional quality and safety of foods consumed in the country). 5.1.6 Support the integration of Hazard Analysis and Critical Control Point (HACCP) approaches in infant and young child feeding programmes. 5.1.7 Support the application of Food Safety Management Systems by value chain actors. 5.1.8 Advocate for establishment of accredited food testing laboratories. 5.2.1 Support the functioning of Consumer Protection Groups. 5.2.2 Strengthen public information and/or educational activities to sensitize the population on quality, safe and nutritious food. 5.2.3 Advocate for the inclusion of Food Standards, Quality and Safety into the Basic Education Curriculum. Targets 1. Number of Regulations gazetted increased from 2 in 2021 to 15 by 2025. 2. Number of national food standards published increased from 25 to 100 by 2025. 3. At least one accredited food testing laboratory established by 2025. 14 6. Nutrition and Infectious Diseases Preamble The interaction between infectious diseases and malnutrition has a major impact on health status, particularly among the vulnerable groups. Malnutrition and infections influence each other through a vicious cycle. Poor nutritional status lowers one’s immune status and this may eventually result to infections. It takes a longer time for poorly nourished individuals to recover from infections. On the other hand, infections often lead to malnutrition, as sick people are often anorexic and may suffer from diarrhoea and mal-absorption as well as increased severity of micronutrient deficiencies. Acute Malnutrition (Severe and Moderate Acute Malnutrition) is one of the most common causes of morbidity and mortality among children under 5 years of age worldwide with 54% of child mortality associated with under nutrition. In The Gambia, the leading Severe Acute Malnutrition (SAM) co-morbidities for children under five years of age in 2015 are: Respiratory Tract Infections (RTI), diarrhoea and malaria (HMIS 2015). At programme level, most malnourished children who fail to respond to treatment tend to have underlying conditions. One very important Improving the nutritional status of people is a major contributor to the prevention and management of infectious diseases. Well nourished people tend to have immunity to resist infections or when infected, take a shorter duration to recover. Some strategies and interventions put in place in The Gambia include the Expanded Programme on Immunisation (EPI), Vitamin A Supplementation and Deworming, Integrated Management of Neonatal and Childhood Illnesses (IMNCI), Malaria Control, Tuberculosis Control, Integrated Management of Acute Malnutrition (IMAM) and the promotion of Water, Sanitation and Hygiene (WASH) in nutrition care. Also being done, is the regular screening of children for malnutrition at RMNCAH clinics and during the bi annual nutrition surveillance. The challenge is to ensure that stakeholders appreciate the importance of good nutritional status in both the management and prevention of infectious diseases. Goal 6.0 To reduce the incidence of malnutrition especially among the vulnerable groups through the management and prevention of infectious diseases. Objectives 6.1 To improve the nutritional status of the population particularly children under five years, adolescents, pregnant women and lactating mothers. 6.2 To ensure that stakeholders appreciate the importance of a good nutritional status in both the management and prevention of infectious diseases. Strategies 6.1.1 Continuous promotion of optimal infant and young child feeding practices at all levels. 6.1.2 Strengthen the screening and management of moderately and severely malnourished children at community and health facility levels. 6.1.3 Support the dietary management of people with infections. 6.1.4 Advocate for standards and the enforcement of legislations and regulations related to environmental sanitation. 6.1.5 Promote quality water, hygiene and sanitation at all levels including in schools. 6.1.6 Advocate for the establishment of nutrition support teams in Paediatric Units of Hospitals. 6.1.7 Advocate for the strengthening of the immunization services and the implementation of the IMNCI, IDSR, IMAM and Maternity Care Guidelines. 6.2,1 Support the systematic collection, efficient management and dissemination of epidemiological information on infectious diseases. 6.2.2 Strengthen SBCC in the prevention and management of infectious diseases. 15 6.2.3 Support the strengthening of inter-sectoral partnership for the reduction of the impact of infectious diseases on the nutritional wellbeing of vulnerable groups. 6.3.4 Advocate for the strengthening of the collection, management and timely reporting of health and nutrition information. Targets: 1. Proportion of households with proper sanitation (toilets) increased from 37% (2013) to 75% in 2025. 2. Maintain the proportion of households with portable water supply above 90%. 3. Maintain the immunization coverage (BCG, Penta3 and Measles) above 90%. 16 7. Nutrition and HIV/AIDS Preamble Nutrition is being increasingly recognized as important in all aspects of human development. Over the years, its relationship with HIV/AIDS has been well documented. Adequate nutrition is important both in the prevention and management of HIV/AIDS. It is well known that nutritional deficiencies affect immune functions in ways that influence viral expression and replication which in turn affect HIV disease progression and eventually mortality. Nutrition also plays a critical role in the comprehensive care and support of people living with HIV and AIDS (PLHIV). Poor nutrition compromises the immune system whereas good nutrition is key in maintaining and improving the nutritional status of PLHIV. In the management of PLHIV, nutritional advice, support, comprehensive care and monitoring are crucial. The HIV Sentinel Surveillance Results (2020) reported that 1.52% of the women were HIV positive which is a slight decrease from 1.82% in 2017. A survey on PLHIV (2011) found that 21.9% were underweight and 16.3% were either overweight or obese. The same study found that only 3.6% were food secure. Over the past years, efforts have been made to address issues relating to nutrition and HIV/AIDS. These include the provision of nutrition support to clients on Anti-Retroviral Therapy (ART), the implementation of the policy on the Prevention of Mother to Child Transmission of HIV (PMTCT), drafting of the Nutrition and HIV/AIDS Policy and the development of a Manual on Nutritional Care and Support for People Living with HIV and AIDS. However, the interventions need to be harmonized and strengthened in scope and coverage. Goal 7.0 To improve the nutritional status and quality of life of people infected and affected by HIV/AIDS. Objectives 7.1 To increase awareness on the relationship between nutrition and HIV/AIDS. 7.2 To provide nutritional information, comprehensive care and support to people infected and affected by HIV/AIDS. Strategies 7.1.1 Intensify Nutrition and HIV/AIDS education through outreach programmes and grass root organizations through collaboration with relevant stakeholders. 7.1.2 Contribute to the promotion of HIV prevention activities. 7.2.1 Implement the guidelines on nutritional care and support for PLHIV. 7.2.2 Build the capacity of community-based service providers on the nutritional care and support to PLHIV. 7.2.3 Support communities to provide care and support for PLHIV. 7.2.4 Support the implementation of the Guidelines on PMTCT. 7.2.5 Strengthen income generating activities for PLHIV. 7.2.6 Advocate for the provision of nutrition support and care to PLHIV. Targets 1. Prevalence of underweight in PLHIV decreased from 21.9% in 2011 to 8% by 2025. 2. Proportion of PHLIV who are food secured increased from 3.6% in 2011 to 10% by 2025. 17 8. Preventing and Managing Diet-Related Non-Communicable Diseases Preamble The Gambia is grappling with the burden of infectious diseases but now non-communicable diseases/conditions (NCDs) such as diabetes, cancer, chronic respiratory conditions and Cardio-Vascular Diseases leading to hypertension and stroke among others, have become public health priorities. The changing lifestyles due partly to urbanization and globalisation have influenced an increased consumption of unhealthy diets such as highly processed, high in fats, sugar and salt, excessive use of tobacco and alcohol as well as stress. Low levels of physical activity also contribute to the increasing prevalence of NCDs. These demographic, nutritional and epidemiological transitions further aggravate the NCD burden. Inadequate investment in prevention is also a major contributing factor to the rapid and continuous rise of the NCD burden in The Gambia. These conditions have serious implications for both the health service and the population at risk. NCDs lower the quality of life of people, impair the economic growth of the country and place a heavy demand on the family and national budget. The 2016 NCDs Country profile by WHO reported that NCDs account for 34% of total deaths, in which, cardiovascular disease was 14%, cancers 4%, chronic respiratory disease 2%, diabetes 1% and other NCDs 12%. The probability of dying between the ages of 30-70 years from the four main NCDs is 19%. Moreover, nationally, 2.1% of children are overweight whereas 22.2% and 14.2% of women 15 – 49 years are overweight and obese respectively (DHS, 2019-20). The STEPWISE Survey (2010) revealed that about 2% of the adult population, aged 25 – 64 years, drink alcohol; the average mean number of days of fruits and vegetable consumption among adult males and females is estimated at 3.3 and 5.0 respectively and about 22% of the adult population have a low level of physical activity. In addressing Diet related NCDs, the following programmes and strategies have been implemented and/or developed: SBCC on the prevention and control of NCDs, the establishment of an NCD Unit in the Ministry of Health, conducting nutrition counselling at NCD clinics, the development of the NCD Policy and the formulation of Food Standards on some foods such as fats and oil. Goal 8.0 To reduce the prevalence of diet-related non-communicable diseases. Objectives 8.1 To increase awareness on the risk factors and major determinants of diet-related NCDs. 8.2 To reduce the mortality associated with obesity and diet-related NCDs. Strategies 8.1.1 Strengthen SBCC on the causes, prevention and management of diet-related NCDs. 8.1.2 Build capacity of health facility and community-based service providers on the prevention and management of diet-related NCDs. 8.1.3 Support the strengthening and broadening of the scope of integrated disease surveillance system. 8.1,4 Strengthen the promotion of optimal maternal, infant and young child feeding practices. 8.1.5 Advocate for increased public recreational facilities and their usage. 18 8.2.1 Strengthen and scale up the nutrition and lifestyle counselling for people with NCDs. 8.1.6 Advocate for the strengthening of Physical and health education in schools. 8.2.1 Promotion of physical activity amongst the adult population. 8.2.2 Advocate for the recruitment, training and deployment of Dieticians to be placed at Hospitals and Major Health Centres. 8.2.3 Coordinate the development of partnership with public, private sector and CSOs in the prevention and management of diet-related NCDs. 8.2.4 Develop Food Based Dietary Guidelines. 8.2.5 Promote the increased consumption of fruits and vegetables. 8.2.6 Advocate for increased funding of interventions for NCD prevention and control Targets: 1. Prevalence of overweight and obesity among adults reduced to below 15% from 23% by the end of 2025. 2. Halt the increase in the prevalence of overweight and obesity amongst children under 5 by 2025. 19 9. Caring for the Socio-Economically Deprived and Nutritionally Vulnerable Preamble Care refers to the provision of time, attention, support and skills to meet the physical, mental and social needs of the socio-economically deprived and nutritionally vulnerable groups in the household and community. Amongst these groups, the growing child is the most vulnerable, but others include women, the elderly, persons with disabilities, internally displaced persons, refugees, those in isolated communities, the rural and urban poor, the unemployed, people living with HIV/AIDS, chronically ill persons, people in institutional care settings such as prisons and hospitals, street children, orphans and children in difficult circumstances. Individuals most at risk of malnutrition are those who are both physiologically vulnerable and socio economically deprived. The overall prevalence of disability in The Gambia is 1.2% (Census, 2013). The Economic Dependency Ratio in The Gambia was 202 per 100 employed persons in 2013 increasing from 182 in 2003 (Census, 2013). In The Gambia, the provision of care is primarily the responsibility of the family. The skills and abilities of the primary care giver, who is usually the mother, are crucial to the quality of care, particularly the selection and preparation of food for the family. The role of government should be to provide a supportive environment for family- and community-based care and direct services when additional care is needed. However, society also has an obligation to assist those who cannot care for themselves. A National Social Protection Policy (2015 – 2025), Child Protection Strategy (2016-2020) and the Minimum Care Standards have been developed and being implemented. The National Social Protection secretariat was established to coordinate all social protection activities in the country. Social transfers are being provided to the poor and the most vulnerable groups and individuals. Goal 9.0 To improve the care and nutritional status of the socio-economically deprived and nutritionally vulnerable groups. Objective 9.1 To establish an effective nutritional care and support system for the socio-economically deprived and nutritionally vulnerable groups. Strategies 9.1.1 Capacity building of care givers for the provision of nutritional care and support to build resilience for the socio-economically deprived and nutritionally vulnerable persons and households. 9.1.2 Strengthen the promotion of optimal maternal, infant and young child feeding practices. 9.1.3 Promote male participation in the provision of nutritional care and support for their families including the elderly. 9.1.4 Advocate for food and nutrition security programmes directed at vulnerable groups. 9.1.5 Support the implementation of the Minimum Care Standards. 9.1.6 Support the implementation of the Social Protection Policy (2015 – 2025). 9.1.7 Advocate for the mainstreaming of the Social Protection Policy in multi-stakeholder programmes. 9.1.8 Promote and advocate for optimal nutrition for refugees, persons with disabilities and persons admitted in institutional care settings such as orphanages, hospitals and prisons. Targets 1. Number of vulnerable households receiving support increased. 2. Production of nutritional support guidelines for people in care institutions by 2022 20 10. Nutrition in Emergencies Preamble All people need to consume quality and safe food for their health and wellbeing. Natural and human induced disasters can cause havoc on the life, livelihood and properties of individuals, families and communities. The Gambia does experience emergencies such as disease outbreaks like COVID-19, windstorms, flash floods, fire, droughts as well as crop failures due to erratic rainfall and/or shortened cropping season and a periodic influx of refugees from the sub-region. The country has not experienced a major situation of internally displaced people caused by conflict or natural disasters, where a community’s capacity to access food is compromised leading to emergency food aid intervention becoming the primary form of assistance. Without access to adequate food, other forms of humanitarian assistance are likely to be less effective. However, in the initial stage of emergencies, timely access to adequate food for the maintenance of a good nutritional status is a critical determinant of peoples’ survival. Malnutrition can be the most serious public health problem and leading cause of death, either directly or indirectly. The most commonly affected are children between the ages of 6 months and 5 years and the elderly, though younger infants (below 6 months), older children (above 5 years), adolescents, pregnant women, breastfeeding women, refugees and other adults may also be affected. For infants and children interrupted breastfeeding and inappropriate complementary feeding increase the risk of malnutrition, illness and mortality. In addressing emergency situations, the Government has established a National Disaster Management Agency (NDMA) and developed a National Contingency Plan. The International Code of Marketing of Breast Milk Substitute has been adopted and made into a regulation (Breastfeeding Promotion Regulation, 2006). However, there is need to incorporate appropriate nutritional support in the policies, programmes and contingency plans of the NDMA and other stakeholders working in emergencies. Goal 10.0 To prevent malnutrition among the vulnerable groups during emergencies. Objective 10.1 To effectively and timely provide food and nutrition response to affected populations in emergencies. Strategies 10.1.1 Support rapid nutritional needs assessment. 10.1.2 Provide nutritional support including emergency food aid where appropriate to the affected population. 10.1.3 Capacity development of stakeholders to manage nutrition in emergency situations. 10.1.4 Develop food and nutrition related disaster preparedness tools and early warning systems. 10.1.5 Provide counselling to mothers, families and care givers to practice optimal maternal, infant and young child feeding in emergency situations. 10.1.6 Strengthen the institutional mechanisms for timely access to adequate, quality and safe food for people in emergency situations. 10.1.7 Advocate for the provision of basic health care, safe water, sanitation and other basic needs. 10.1.8 Develop guidelines for coordination and delivery of nutrition supports and care during emergency. 10.1.9 Support affected communities and individuals to build resilience (building back better). 10.1.10 Advocate for the enforcement of the Breastfeeding Promotion Regulation, 2006. 10.1.11 Support the mainstreaming of nutrition into national emergency contingency plans. 10.1.12 Advocate for involvement of the private sector and other stakeholders in nutrition support. 21 Targets 1. Nutritional care and support mainstreamed in the National Disaster Contingency Plan by 2025. 2. Nutritional management of diseases mainstreamed in the Emergency Disease Preparedness Plans by 2025. 22 11. Nutrition Surveillance Preamble Nutrition Surveillance is a crucial element and vital tool for effective management of nutrition situations. It is also important for evidence-based planning, informed decision-making and monitoring and evaluation of all nutrition situations. Data collection, analysis and general monitoring of nutrition situations should be timely and managed by well-trained and competent staff. The Gambia Nutrition Surveillance Programme (GNSP) was first piloted in 1984 before being expanded to all Primary Health Care (PHC) villages. It is the most institutionalised Nutrition programme, conducted twice each year covering children 6-59 months in all the PHC villages. However, the GNSP which is limited to only children under 5 years, needs to be scaled up to non PHC villages. The GNSP is being used as one of the bases for the development of an Early Warning System and to identify the most effective intervention strategies to prevent or address existing and/or emerging nutritional situations and for targeting. The nutrition surveillance methodology previously used the Nabarro Thinness Chart but now uses of the Mid Upper Arm Circumference (MUAC) tape. The use of the MUAC and the presence of bilateral oedema is valuable in tracking Global Acute Malnutrition (GAM) trends in the country. Therefore, the surveillance provides information on areas with high burden of acute under-nutrition and can be compared to other survey data. Over the past few years, active screening for acute malnutrition amongst children under 5 years has been initiated with the training of mothers on the use of the MUAC tapes to assess the nutritional status of their own children at community level. Goal 11.0 To achieve an effective and efficient Nutrition Information System (NIS) for informed decision making, policy formulation and programming. Objective 11.1 To make nutrition information available to all stakeholders for appropriate planning, policy development, programming and decision making. Strategies 11.1.1 Develop a protocol and guidelines for the nutrition surveillance programme. 11.1.2 Strengthen institutional capacity at all levels, to efficiently assess, compile, analyse and monitor nutrition and nutrition related situations. 11.1.3 Expand the scope of the nutrition surveillance programme to include other nutrition related indicators. 11.1.4 Advocate for the inclusion of nutrition indicators in all national household surveys. 11.1.5 Support the establishment of an effective integration mechanism for all organizations and stakeholders involved in assessing, analysing, monitoring and evaluating nutrition and nutrition related surveillance data. 11.1.6 Awareness creation of all stakeholders including the households on the importance and use of the Nutrition Information System. 11.1.7 Disseminate nutrition and nutrition related information to all stakeholders including the households. 11.1.8 Incorporate nutrition indicators into the Early Warning Systems. 11.1.9 Support the community-based Mother MUAC programme. 11.1.10 Scale up nutrition surveillance to all communities. Targets 1 Number of communities carrying out active screening increased from 11 (2016) to 100 in 2025 2 Number of children assessed during each nutrition surveillance increased to 80,000 23 12. Nutrition Research Preamble Nutrition Research is the pursuit of new knowledge to improve the understanding between nutrition and human health and encompasses studies in five major areas: biomedical and behavioural sciences, food sciences, nutrition monitoring and surveillance, nutrition education and impact on nutrition intervention programmes and socio-economic factors. Nutritional epidemiology being the main driver of human nutrition research focuses specifically on the relationship between diet and disease. It combines nutritional knowledge with epidemiological methods developed to investigate the determinants of health and disease in populations including nutritional disorders. It also proposes measures in addressing and controlling these deficiencies. Appropriate human nutrition research can inform the development of nutrition policy and thus enable policy makers and other stakeholders understand how cultural, socio-economic and environmental factors affect nutritional status and wellbeing of populations. The Gambia is well known around the world in the area of nutrition research through work done by Medical Research Council The Gambia at the London School of Hygiene and Tropical Medicine and its Nutrition Theme and to some extent the National Nutrition Agency. Despite all the work done on nutrition research so far, there are still gaps (not enough data) regarding the magnitude of some of the nutritional problems in the country. As knowledge on the relationship between diet and health has increased, so also are concerns on the role of hunger, undernutrition, food insecurity, overweight, obesity, dietary knowledge, attitudes and behaviour on overall wellbeing of populations. This necessitates the building up of knowledge and skills through nutrition research for effective and efficient nutrition interventions. It is not only enough to conduct relevant research but to create the enabling environment to communicate research findings to policy makers, colleagues and the general public. There is need to adopt relevant nutrition research methodologies that are expanded to cover the basic nutrition sensitive and specific interventions annually. Nonetheless, other periodic surveys can also be undertaken to provide information on human nutrition and its related interventions to inform efficient policy decision making. Even though there is a lot of research conducted in the country, the findings of these studies are rarely translated into policy and programmes. Goal 12.0 To promote excellence in human nutrition research in The Gambia. Objective 12.1 To create an enabling environment for human nutrition research. Strategies 12.1.1 Strengthen and/or establish nutrition research coordination mechanisms at the national level. 12.1.2 Build national capacity in nutrition research. 12.1.3 Strengthen collaborative research with academia and other stakeholders in the generation of data in relevant areas. 12.1.4 Support the dissemination of research findings. 12.1.5 Strengthen the development of evidence-based nutrition related policies, strategies and interventions. Target 1. Engage in at least 5 nutrition research topics with academia or research institutions 24 13. Social and Behaviour Change Communication (SBCC) Preamble Good nutrition enables a society to be easy to educate, active and productive. People who are “nutritionally literate” know how to make good food and lifestyle-choices and develop good eating habits for themselves and for others, which enhances their health and well-being. One of the most appropriate and effective means of making people “nutritionally literate” is through Social and Behavioural Change Communication (SBCC), which affords people the knowledge, skills and motivation needed to make wise dietary and lifestyle choices, and build a strong foundation for a healthy and productive life. SBCC has evolved from Information, Education and Communication (IEC) and health education, which in the past, focused on the power of communication to influence individuals to change their health behaviors through the provision of information. Many interventions are based on theories that individuals will take steps to avoid risks if they are fully informed, but it is known that simply giving correct information - while important - does not automatically change behavior by itself, and focusing at the individual level is not enough either. The focus then shifted to Behaviour Change Communication (BCC), which emphasized analysis of behaviours and determinants to affect changes in knowledge, attitudes and practices. Now, the focus is on SBCC, which employs a more comprehensive approach. An SBCC Strategy provides the national framework to guide the delivery, monitoring and evaluation of communication interventions for improved nutrition and health outcomes and ownership by the communities and other stakeholders. Therefore, the policy will use the Strategy in implementing health and nutrition interventions. It is believed that nutrition education, particularly in schools, can contribute significantly to sustainable development in poor countries. School-based nutrition education, properly done, touches on the three particularly important pillars among those that form the basis of a thriving nation, namely: nutrition, health and education. These three have a mutually reinforcing relationship that must be strengthened. To facilitate nutrition education, a National SBCC Strategy was developed with the National SBCC Multi sectoral Working Group in which the Directorate of Health Promotion and Education is a key member. Teaching and Learning Materials for Lower Basic Schools have also been developed in collaboration with MoBSE and Gambia College. Other interventions being implemented include nutrition counselling at clinics and in communities. Goal 13.0 To create an informed society that adopts optimal nutrition behaviours. Objective 13.1 Mobilize communities and key influencers to create and support long term normative shift towards desired positive health and nutrition behaviours. 25 Strategies 13.1.1 Support the mass and traditional media to inform, communicate and educate the Gambian populace on nutrition and nutrition-related activities. 13.1.2 Build the capacity of advocacy groups, community structures and stakeholders to fully participate, formally and informally, in social and behavioral change communication and related activities. 13.1.3 Advocate for the strengthening of nutrition education in the curriculum at all levels of the country’s education system. 13.1.4 Support effective community mobilization for social and behaviour change. 13.1.5 Strengthen coordination mechanisms of nutrition education programs and activities in the country. 13.1.6 Advocate for introduction of school friendly nutrition initiative Target 1. Nutrition Communication Strategy finalised and in use. 26 14. Resource Mobilisation Preamble The Government of The Gambia through the National Nutrition Agency (NaNA) under the Office of The Vice President is committed to the fight against malnutrition as an integral part of poverty reduction efforts. Together with other partners, NaNA has made some tremendous achievements in the field of nutrition over the past few years and nutrition has now been accorded a high priority in the socio-economic development agenda of the country. This is as a result of the recognition of the fact that for any meaningful and effective development to take place, people of a nation should be well nourished and healthy. Nutrition can be both an input and an output of socio-economic development and therefore providing resources for nutrition specific and sensitive interventions is necessary. Investing in nutrition will enable the country make considerable progress in meeting its SDG targets and the National Development Plan (2018-2021). Despite the tremendous achievements made with the limited resources available over the years, progress in meeting global and national targets has slowed requiring a sustained effort in mobilizing adequate resources not only in terms of trained, qualified, skilled and experienced personnel but also technical, financial and material resources to support a coordinated response to the nutritional problems. The Agency is a semi autonomous institution which has been mandated to mobilize resources for its functions and nutrition programming in the country. It is expected that the Agency’s overall strategic and business plans as well as the Nutrition PROFILES, COHA, 2019, and other assessments like the Joint Annual Assessment of the country SUN Multi-sectoral Platform will form the basis for mobilization of the resources required for investing in cost effective nutrition interventions. Investing in nutrition is actually investing in the future of The Gambia. Over the years and since the establishment of NaNA, the Government has proved its commitment to ensuring nutrition security to the population through the provision of funding to maintain and adequately staff the Agency and supported the Agency with its resource mobilization drive. There has been a noticeable increase in funding for both nutrition specific and nutrition sensitive interventions from traditional and new sources such as government, World Bank, EU, UN Agencies (especially UNICEF, WFP, FAO and WHO), CILSS and WAHO. Goal 14.0 To secure adequate and sustainable resources for effective nutrition programming at all levels. Objectives 14.1 To increase the resource base of the Agency for effective functioning and investment in nutrition. 14.2 To create an enabling environment to facilitate resource mobilization for multi-stakeholders for the effective and efficient implementation of nutrition specific and sensitive programmes. 14.3 To coordinate investment and track and report on resources invested in nutrition. Strategies 14.1.1 Develop innovative resource mobilisation framework for both traditional and non-traditional partners. 14.2.1 Update the Strategic Plan and Business Plan for nutrition investment and coordination. 14.3.1 Develop mechanisms for rapidly correcting problems identified in consultation with stakeholders and development partners. 14.3.2 Provide satisfactory reports and information on the use of government and donor funds. 14.3.3 Advocate for increment of government budgetary contribution to nutrition. 14.3.4 Advocate for the coordination of donor support for nutrition activities in The Gambia. 14.3.5 Advocate for and pursue partnership with both public and private sector investment in nutrition programs. 27 14.3.6 Promote corporate alliances and pledging for nutrition investment. 14.4.2 Advocate with Ministry of Finance and Economic Affairs to organize donor meetings/round tables for resource mobilization for nutrition. Targets 1 Resources mobilized for nutrition increased by 2025. 2 At least 2 Reports on Financial Tracking for nutrition produced by 2025. 3 A Costed Strategic Plan and Business Plan for Nutrition produced. 28 15. Mainstreaming Nutrition into Development Policies, Programmes and Legislations Preamble Hunger and malnutrition are integral components of the inter-connected and overarching problems of poverty and deprivation. The Sustainable Development Goals (SDGs) and the National Development Plan (NDP) have recognised hunger and malnutrition as significant factors impeding sustained human development. The challenges of the hunger and malnutrition complex are multi-faceted, including incoherent and uncoordinated multi-sectoral approaches and limited public-private-civil society partnership. Within the macroeconomic and sectoral policies, planning and budget development framework (including decentralised levels) there are no systematic approaches to mainstreaming nutrition. The importance of nutrition to overall development, due to its cross-cutting characteristics, makes it imperative to mainstream it into national development policies, programmes and budgets. This underscores the importance of nutritional well-being of the population as the nutritional status of the people is an indicator of a country’s level of socio economic development. Over the years, efforts have been made to mainstream nutrition into several national policies such as the National Health Policy (2012 – 2020), the Agriculture and Natural Resources Policy (2017 – 2025), National Agriculture Investment Plan and the Education Sector Policy (2016 – 2030). However, little was achieved in mainstreaming nutrition into other sectoral policies and programmes and their implementation. Efforts are continuing to mainstream nutrition into relevant policies, programmes and legislations. Goal 15.0 To mainstream nutrition into national and decentralised policies, legislations and programmes. Objective 15.1 To ensure that nutrition is mainstreamed in key development policies, legislations and programmes. Strategies 15.1.1 Provide adequate staff and resources for the effective coordination and functioning of the Planning, Research and Resource Mobilization Directorate of NaNA. 15.1.2 Support the capacity building of other Planning Units in nutrition planning, programming and mainstreaming. 15.1.3 Facilitate and support the establishment and functioning of networks of public, private sector and Civil Society Organizations for nutrition advocacy, networking, dialogue and action. 15.1.4 Facilitate the incorporation of nutrition issues in sectoral policies, legislations and programmes. 15.1.5 Strengthen the functionality of nutrition governance and strategic management structures at national and decentralized levels. Target 1. Nutrition mainstreamed into 5 sectoral policies. 29 16. Policy Implementation Framework Preamble The National Nutrition Agency (NaNA) was established by the Food Act 2005. NaNA as a legal entity is mandated to coordinate nutrition, nutrition-related activities and advocate for the mainstreaming of nutrition into the macroeconomic and sectoral policy frameworks in The Gambia. The Agency over the period has strengthened the implementation capacity by staffing the Programme Directorates with relevant and experienced staff for effective implementation of the Policy. Structures The institutional arrangement is legislated for the implementation of the Nutrition Policy, namely: 1. A National Nutrition Council (NNC) composed of the following:  Vice President (Chairperson)  Minister of Health  Minister of Gender, Children and Social Welfare  Minister of Fisheries, Water Resources and National Assembly Matters  Minister of Agriculture  Minister of Basic and Secondary Education  Minister of Finance and Economic Affairs  Minister of Trade, Industry, Employment and Regional Integration  Minister of Lands and Regional Governance  Minister of Higher Education, Research, Science and Technology  Minister of Youth and Sports  Minister of Information, Communication and Infrastructure  Chairperson - NaNA Board  Director General - NaNA (Secretary) The Council is responsible for:  Ensuring political commitment and prioritization of nutrition in national development  Ensuring cross sectoral coherence  Advocating for increased support for nutrition. The Chairperson shall preside at every meeting of the Council at which she or he is present and in her or his absence, the members present shall appoint one of their members to preside over the meeting. The minutes of every meeting of the Council shall be recorded and signed by the Secretary and the person who presided over that meeting after confirmation by the Council. The Council may at any time co-opt any competent Agency, institution or person to participate in their meeting. 2. The National Nutrition Agency (NaNA) Board of Directors composed of the following as per the Food Act 2005:  A Chairperson  Director General of NaNA  Permanent Secretary Office of The Vice President 30  Permanent Secretary, Ministry of Finance and Economic Affairs  2 Representatives of the Civil Society  A Secretary 3. The National Nutrition Agency (NaNA) headed by the Director General assisted by a Deputy Director General and Programme Directors  The Office of the Director General: responsible for the day-to-day administration and management of the Agency.  Directorate of Nutrition Programming: responsible for implementation of nutrition programmes and reports to the Deputy Director General.  Directorate of Planning, Research and Resource Mobilization: responsible for Planning, Monitoring and Evaluation, Research and Documentation and reports to the Deputy Director General.  Directorate of Finance and Administration: responsible for the Financial Management, Accounting and Administrative matters and reports directly to the Director General.  Directorate of Social and Behaviour Change Communication: responsible for advocacy and communication and reports to the Deputy Director General. The Agency is headed by a Director General who reports to the Board of Directors and Office of The Vice President as its oversight Ministry. NaNA’s core responsibilities include the following:  Coordination of policy implementation  Implementation of nutrition activities  Secretariat of the National Nutrition Council  Nutrition Policy Analysis, Research and Indicative Planning  Monitoring of Nutrition interventions and programmes  Mobilisation, Management and Coordination of Resources 4. In addition to the above structures, the Nutrition Technical Advisory Committee (NTAC) also referred to as the Multi-Stakeholder Platform (MSP) at the central level comprising of Heads of Departments/Units of key sector institutions, relevant Agencies, NGOs and private sector representatives will provide technical support to NaNA and ensure sectoral and institutional linkages and collaboration. 5. At the regional level, NaNA is represented at the Regional Technical Advisory Committee for effective coordination and monitoring of nutrition and nutrition related interventions. At the community level, NaNA will work through and with existing local government and community-based structures to implement the policy. For the successful implementation of the National Nutrition Policy 2021 - 2025 a Nutrition Bill has been drafted awaiting enactment. A National Nutrition Stakeholders Forum shall be convened on topics of interest when the need arises. The forum will serve as a platform/mechanism for, dialogue, engagement and information sharing. The membership will include the Government and non-state actors (private, civil society, expert and development partners). 41 INSTITUTIONAL FRAMEWORK National Nutrition Council National Nutrition Agency (NaNA) Director General DPRRM DSBCC DNP NTAC and RTAC (Central and Regional) Office of the Vice President Board of Directors DFA Deputy Director General 42 17. Human Resources for Effective Policy Implementation Preamble Adequate, well trained and competent human resources are required to efficiently and effectively implement the mandate that NaNA and other stakeholders are entrusted with. The retention of the existing staff is crucial to not only maintain the momentum but also ensure the effective utilisation of knowledge, skills and abilities. Likewise, it is also imperative that stakeholders are able to attract well qualified and competent staff with the appropriate ability, ambition and integrity in the drive to attain optimal nutritional status for the Gambian population. Goal 17.0 To ensure availability of competent human resources for effective implementation of the Nutrition Policy. Objective 17.1 Retain existing and recruit additional staff as per the Scheme of Services. Strategies 17.1.1 Support effective functioning of the Directorates of NaNA. 17.1.2 Support the development of a Human Resources Capacity Needs Assessment Framework. 17.1.3 Support capacity building for relevant actors engaged in the implementation of the policy. 17.1.4 Support the development of a training policy. 17.1.5 Advocate for the introduction of nutrition courses in the tertiary institutions. Target 1. At least one Dietician appointed by the Edward Francis Small Teaching Hospital. 43 18. Monitoring and Evaluation Preamble Monitoring and evaluation is an integral part of programme implementation. It is a tool that provides vital information for effective decision making and planning. It enables implementers, beneficiaries and donors to assess the progress and impact of programs. It also helps programs check if objectives are realistic, appropriate and achievable within a given time, or if they require adjustment. Evidence based decision making is vital for the attainment of desired goals. Over the years, efforts have been put in place to integrate monitoring and evaluation into nutrition program implementation. This has led to the creation and staffing of an M&E Unit under the Directorate of Planning, Research and Resource Mobilization in NaNA. As there is the need for a sector-wide approach to monitoring and evaluating nutrition programming as nutrition is cross-cutting, the Agency together with partners are developing a Common Results Framework (CRF) to facilitate the monitoring and evaluation of all nutrition interventions in the country. Goal 18.0 To routinely monitor the national nutrition programmes. Objective 18.1 To provide up to date information for evidence-based decision making. Strategies 18.1.1 Develop a comprehensive nutrition M&E Strategy. 18.1.2 Support the implementation of the nutrition M&E Strategy. 18.1.3 Support the development and implementation of a Common Results Framework (CRF) for Nutrition. Target 1. A Nutrition M&E Strategy finalized and being used. 2. A Common Results Framework for Nutrition finalized.