Lesotho Food and Nutrition Security Strategy and Costed Action Plan (2019–2023)

2019 - 2023 Maseru, March 2019 2023 Lesotho Food and Nutrition Strategy and Action Plan Page ii LESOTHO FOOD AND NUTRITION STRATEGY AND COSTED ACTION PLAN 2019 - 2023 FINAL COSTED VERSION (For Validation) STRATEGY DRAFTING TEAM 25 March 2019 Lesotho Food and Nutrition Strategy and Action Plan Page iii ACRONYMS FNASP Food and Nutrition Strategy and Action Plan LFNSAP Lesotho Food and Nutrition Strategy and Action Plan KRA Key Result Area M&E Monitoring and Evaluation NCDs Non-communicable diseases COHA Cost of Hunger Assessment LDHS Lesotho Demographic Health Survey WHOO World Health Organisation DHS Demographic Health Survey GDP Gross Domestic Product HIV Human Immuno Deficiency Virus WASH Water Sanitation and Hygiene NEPAD New Partnership for Africa's Development UNDP United Nations Development Programme WFP World Food Programme UNICEF United Nations Children Fund IYCF Infant and Young Child Feeding ANC Antenatal Care SADP Smallholder Agricultural Development Programme FAO Food Agriculture Organisation MAFS Ministry of Agriculture and Food Security ERP Emergency and Resilience Programme JADAFA Joint Agri-Business and Department of Agriculture Forum for Africa FNCO Food and Nutrition Coordination Office UN United Nations MoH Ministry of Health PMTCT Prevention of Mother to Child Transmission ART Anti-Retroviral Treatment AU African Union REACH Renewed Efforts Against Child Hunger and Under-Nutrition MNO Malnutrition Overview NGO Non-Governmental Organisation USD United States Dollars TB Tuberculosis IMCI Integrated Management of Childhood Illnesses PHC Primary Health Care OVC Orphans and Other Vulnerable Children AJR Annual Joint Review WHZ Weight for Height Z-Score HAZ Height for Age Z-Score SD Standard Deviation BMI Body Mass Index RMNCAH Reproductive, maternal, new-born, child and adolescent health LRFS Lesotho Risk Factor Survey IARC International Agency for Research on Cancer LVAC Lesotho Vulnerability Assessment Committee MCP Multiple and Concurrent Partnerships GoL Government of Lesotho SWOT Strengths Weaknesses Opportunities and Threats Lesotho Food and Nutrition Strategy and Action Plan Page iv SADC Southern African Development Community SUN Scaling Up Nutrition ICTs Information Communication Technologies MoAFS Ministry of Agriculture and Food Security MoET Ministry of Education and Training ECCD Early Childhood Care and Development EGPAF Vacancies with Elizabeth Glaser Paediatric AIDS Foundation Lesotho Food and Nutrition Strategy and Action Plan Page v TABLE OF CONTENTS ACRONYMS .................................................................................................................................... iii TABLE OF CONTENTS ................................................................................................................... v 1 CHAPTER 1: INTRODUCTION ................................................................................................ 1 2 VISION, MISSION AND PRINCIPLES ................................................................................... 10 3 TERMS OF REFERENCE AND FUNCTIONS OF GOVERNMENT AGENCIES WITH NUTRITION IMPLEMENTATION MANDATES ...................................................................... 11 4 THE FOOD AND NUTRITION SITUATION AND KEY FEATURES OF THE OPERATING ENVIRONMENT ..................................................................................................................... 14 4.1 Nutrition Situation ........................................................................................................... 14 4.1.1 Women of child bearing age (15-49 years)............................................................. 14 4.1.2 Infants (0-6 months) ................................................................................................ 15 4.1.3 Children (6-23months) ............................................................................................ 16 4.1.4 Children under Five (U5) years (< 5 years) ............................................................ 17 4.1.5 Adolescents (10-24 years) ...................................................................................... 20 4.1.6 Young Adults, Adults and Elderly............................................................................ 20 4.2 Overview of the HIV and AIDS Situation ........................................................................ 21 4.3 An overview of the food security situation ...................................................................... 22 4.3.1 Food Accessibility and Affordability ........................................................................ 23 4.3.2 Food Utilization ....................................................................................................... 23 4.3.3 Dietary Diversification ............................................................................................. 24 4.4 SWOT Analysis ............................................................................................................... 25 4.5 Political, Economic, Social, Technological, Environmental and Governance Situation . 26 4.5.1 Political Analysis ..................................................................................................... 26 4.5.2 Economic Analysis .................................................................................................. 26 4.5.3 Social Analysis ........................................................................................................ 27 4.5.4 Technological analysis ............................................................................................ 28 4.5.5 Information Communication Technologies for Nutrition ......................................... 28 4.5.6 Food Fortification .................................................................................................... 28 4.5.7 Energy ..................................................................................................................... 29 Lesotho Food and Nutrition Strategy and Action Plan Page vi 4.6 Environment and Climate Change ................................................................................. 29 4.7 Nutrition Governance Situation ....................................................................................... 29 5 KEY RESULT AREAS ............................................................................................................ 31 5.1 Process of Identifying, and Criteria for Prioritising the Key Result Areas (KRAs) ......... 31 5.2 Weighting of the Key Result Areas ................................................................................. 31 6 CLIENT’S NEEDS AND PROBLEM ANALYSIS .................................................................... 33 7 STAKEHOLDER ANALYSIS .................................................................................................. 36 8 POLICY REQUIREMENTS .................................................................................................... 37 9 CHAPTER 9: GOALS OF THE STRATEGY .......................................................................... 39 10 STRATEGIES, ASSUMPTIONS AND RISKS ........................................................................ 42 11 IMPLEMENTATION PLAN ..................................................................................................... 82 12 STRATEGIC RESULTS FRAMEWORK AND M&E PLAN .................................................... 94 13 RESOURCE REQUIREMENTS ........................................................................................... 101 14 ANNEX 1: GLOSSARY OF TERMS ..................................................................................... 105 15 ANNEX 2: REFERENCES .................................................................................................... 109 16 ANNEX 3: DETAILED ACTIVITIES, ANNUAL OUTPUT TARGETS AND COSTS ............. 111 Lesotho Food and Nutrition Strategy and Action Plan Page vii FOREWORD THE GOVERNMENT OF LESOTHO remains committed to support all efforts in the fight against hunger and achieving prosperity for the people of Lesotho. This commitment to a healthy and well-developed human resource base is well articulated in the National Vision 2020. The Food and Nutrition Security Policy (2016), proposed Food and Nutrition Strategy and the Zero Hunger Strategic Review Report (2018) all provide a framework to address the multi-dimensional causes and consequences of malnutrition. As a country, government has demonstrated its commitment to achieve the World Health Assembly Targets 2025, the African Union Agenda 2063 Goals as well as the Sustainable Development Goal (SDG) target 2.2 -to end all forms of malnutrition by 2030. Indeed, Lesotho is among the seven countries in the world that has shown progress in improving child nutrition outcomes, as evidenced by the 6-percentage point reduction in stunting in the past five years. However, the stunting rates still remain unacceptably high at 33.2 percent among children under 5, indicating an underlying food and nutrition security challenge. Similarly, micronutrient deficiencies among children aged 6 to 59 months particularly iron deficiency anaemia stands at 51 percent. In addition, over 27 percent of girls and women and 14 percent of boys and men in the 15-49 age range are also anaemic. As a national response to this scourge, the Government of Lesotho is intensifying its efforts collectively through various initiatives at all levels. This is exemplified by the launching of the following; The Food and Nutrition Policy, The Cost of Hunger in Africa-Lesotho Study both in 2016, The Zero Hunger Review Report in 2018, to mention but a few. As a result, this Food and Nutrition Strategy will serve as a tool to turn the above into a reality. This Food and Nutrition Strategy provides an overarching framework, covering the multiple dimensions of food and nutrition improvement. The strategy has been developed to add value and strengthen synergy among sectors and other initiatives of government and partners. It recognizes the need for public and private sector involvement, and that hunger eradication and nutrition improvement is a shared responsibility of all Basotho. It is further designed to address malnutrition and extreme hunger across different levels of the nation ranging from the individual, household and communities, thus contributing to the overall national development. The strategy will also be a guiding document for national food and nutrition stakeholders, including government and development partners to promote evidence-based programming and strengthening of the national nutrition response, scale-up of evidence- based innovative interventions, re-alignment of nutrition interventions to the current national development strategy, the Sustainable Development Goals, and other new global declarations, which the government of Lesotho is a signatory. As I always say, Investing in food and nutrition security is moral and economic imperative which should be everyone’s business. Indeed, as the FAO Special Ambassador for Nutrition and African Union Commission Nutrition Champion, I consider it my honor and commitment to lead the fight against hunger and malnutrition I therefore edge every citizen from all walks of life including United Nations Organizations and all our development partners, to embark and participate in the implementation of this Lesotho Food and Nutrition Strategy and Action Plan Page viii strategy. By its cross-cutting nature, it inevitably requires, among others, the participation and involvement of stakeholders at all levels from the community to the national level, including the public sector (Line Ministries, Agencies and Local Government Authorities); higher learning and training institutions, professional bodies, private sector, development partners, civil society, the media and the community at large. Addressing issues of food and nutrition security remains top on the agenda of Government, and as such, my government shall assume primary responsibility for resource mobilization funding the strategy and delivering targets set, while the development partners will complement Government’s efforts. The Office of the Prime Minister through its Food and Nutrition Coordinating Office (FNCO), shall spearhead the implementation of the strategy with the envisaged Food and Nutrition Commission and its structures which will maintain coordination of multiple stakeholders. My government sincerely appreciates and acknowledges all the support rendered by various stakeholders by their seamless contributions in developing this strategy. Signature, His Majesty King Letsie III Lesotho Food and Nutrition Strategy and Action Plan Page ix ACKNOWLEDGEMENTS The development of the Lesotho Food and Nutrition Strategy and Costed Plan of Action emanates from a long consultative process through the experience and immense contribution of diverse representation of various sectors, organizations and individually. Gratitude and appreciation are extended to His Majesty King Letsie III for providing support unstintingly and tirelessly to all the efforts expended on behalf of nutrition in Lesotho. Without his encouragement, advocacy, support and personal involvement, this Strategy would not have come to be. Special thanks go to Irish Government for having financially supported Lesotho through the Renewed Effort Against Child Hunger and under nutrition (REACH) initiative, outcome of which, this Strategy was developed. These efforts were spearheaded and jointly coordinated by of the UN Network for SUN/REACH Secretariat, through Hajra Hafeezurrehman, under the direct leadership Purnima Kashyap. The technical stewardship and guidance provided by our consultant Mr. Munhamo Chisvo throughout this long multi-sectoral and multi-stakeholder participatory approach is commendable and it assures full ownership in the implementation of this national guiding tool. His nurturing, perseverance and dedication to the assignment is well acknowledged. The support and guidance provided by the Lesotho UN Network through the following Heads of Agency; Mary Njoroge (WFP), Cornelia Atsyor (WHO), Mokitinyane Nthimo (FAO) and Nadi Albino(UNICEF) is commendable. Special thanks also are given to the following REACH/UNN focal points, who through their seamless efforts provided with their technical expertise, information and guidance in terms of content of this document during the process of; shared drafts, validation and elicit feedback, they are: Merlyn Chapfunga (WFP), Lineo Mathule (UNICEF), Mantsane Bolepo Tsoloane (WHO). On the other hand, the technical and administrative guidance provided by the World Food Programme (WFP) Country Office Director, Mary Njoroge, her deputy, Marian Yan and Nutrition Unit team and all WFP staff, cannot be overemphasized. The catalytic roles played by National REACH Facilitator, Maseqobela Williams, under the stewardship of; Masekonyela Sebotsa (Director of Food and Nutrition), Mapaballo Putsoa the (REACH Focal Point-FNCO), Molulela Matseleng Mojakhomo (lead Focal Point of this Strategy) and the entire Food and Nutrition Coordinating Office team (centrally and at district levels), is greatly acknowledged. The Core Technical Nutrition Team and all stakeholders-at- large, who participated fully, providing their knowledge, expertise and commitment in the entire formulation process, your efforts are highly appreciated. Gratitude to all who directly or indirectly contributed to this Food and Nutrition Strategy and Costed Action Plan. As Government of Lesotho we look forwards to your continued support and joined efforts towards implementation of this strategy which ultimately will lead reaching our goal of zero hunger by 2030. Signature, Honourable Minister to Prime Minister’s Office Mr. Temeki Tsolo (MP) Lesotho Food and Nutrition Strategy and Action Plan Page 1 1 CHAPTER 1: INTRODUCTION 1.1 Overview This document articulates the national Food and Nutrition Strategy and Action Plan (FNSAP) for Lesotho for the period 2019-2023. It defines the national medium-term strategy for food and nutrition security together with a costed action plan, both of which shall guide design and implementation of food and nutrition security programmes, projects and related actions by all stakeholders. It presents evidence-based high-return investments that have been identified and prioritised through a multi-sectoral consultation approach. The strategies are aligned with national development priorities and goals in the NSDP, regional policies and protocols on food and nutrition security, and relevant international commitments such as the SDGs and the World Health Assembly Targets. The LFNSAP provides guidance to actors when developing food and nutrition interventions and M&E frameworks. In addition to the background chapters analysing the current situation, it spells out the key result areas (KRA) where investments should be intensified, the goals to be achieved under each KRA, key strategies to be pursued in order to attain the goals, assumptions and risks, the implementation plan, results to be achieved along with the indicators and targets to enable performance monitoring and assessment. A detailed budget estimate is also provided for each strategy and its activities under the respective goals. 1.2 The Nature and Magnitude of the Food and Nutrition Insecurity Problems 1.2.1 The Nutrition Situation in Lesotho The nutrition situation in Lesotho is characterised by high stunting rates in children under the age of five years, wide-spread micro-nutrient deficiencies in children, adolescents and adults, overweight and obesity in some segments of the population, and the growing incidence of diet related non-communicable diseases (NCDs) which are costing lives and imposing a burden on the health budget. Stunting At least one in three children under the age of five years is stunted (33.2 percent according the Lesotho Demographic Health Survey of 2014). Whilst both chronic and acute malnutrition in this age group of children has decreased since 2004, stunting remains high and above the WHO public health threshold of 29 percent for moderate prevalence. Chronic malnutrition is high across all districts, especially in Butha-Buthe (40.3 percent), and the mountain districts of Mokhotlong (47.7 percent) and Thaba-Tseka (40 percent). The population density varies by districts with the largest number of children chronically malnourished in the higher population districts of Maseru, Leribe and Mohale’s Hoek. Two of the districts with the highest stunting rates (Mokhotlong and in Thaba-Tseka) have extreme concentrations of poverty. The majority of the population in these districts is in the lowest wealth quintile (53% and 55%, respectively). About 45 percent of the adult population in Lesotho is stunted (COHA Lesotho, 2016). Wasting Across all districts, the prevalence of wasting remains low (under 5%). The districts with the largest number of children under five with acute malnutrition are Maseru, Leribe and Berea. Micro-nutrient deficiencies According to the LDHS, 2014 Report, half of all children have some form of anaemia whilst more than one in four women (27.3%) of age 15-49 years have anaemia. The prevalence of anaemia Lesotho Food and Nutrition Strategy and Action Plan Page 2 in women and children has remained a critical public health issue since 2004 and has increased in recent years. Vitamin A deficiency among pre-school aged children was identified as a severe public health problem in 2005, with 32.7% of these children being affected (WHO, 2007)1. However, updated data is missing. The same applies to iodine deficiency in all school-aged children as one-fifth were deficient in 2002 but more recent statistics are not available. 1.2.2 The Food Security Situation in Lesotho Although the population at risk of food security in Lesotho varies each year, from 2013 to 2016 it increased to as high as 30 percent of the population (679,437) due to a combination of droughts, lack of financial resources (due to rising poverty) to purchase inputs to increase productivity, land degradation, weak management of the sector, limited extension service delivery to farmers contributing to sub-optimal application of modern agricultural methods, pest and disease outbreaks (such as army-worm infestations), limited grazing land and stock theft. In the 2017/18 consumption year 224,664 people in the rural areas and about 82,278 people within urban settlements have been estimated to be food insecure2. Lesotho remains reliant on imports from South Africa to meet its 70 percent of its food security needs. Food insecurity is further characterised by inadequate dietary intake among both children and adults. According to the DHS 2014 report, only 11 percent of children aged six to 59 months received minimum acceptable diet. Fewer than half of all children 6-23 months (40.5%) consume iron rich foods, across all age groups and household settings. Three fifths of children 6-23 months (60.5%) consume foods rich in vitamin A, however the closer to 23 months a child is the more likely they are to consume vitamin A rich foods. 1.2.3 The Global Nutrition Situation Food and nutrition insecurity is a global challenge, and Lesotho is not alone. Worldwide 55 million children under 5 years are stunted while 52 million are wasted2. In Africa alone, 17 countries have stunting rates above 40 percent and 36 countries have rates above 30 percent (36.9 million children under the age of five years) (COHA Lesotho, 2016). 1.3 The Consequences of Food and Nutrition Insecurity Maternal deaths In adult women of reproductive age, consequences of anaemia prevalence, manifest in increased risk of maternal and perinatal mortality, intra-uterine growth retardation and premature births. Child deaths One of the major consequences of child malnutrition is child death. About 19.5% of all child mortality in Lesotho are associated with undernutrition. Anaemia prevalence in under-fives reduces immunity, and increases susceptibility to disease infections. Vitamin A deficiency in pre- school children has a reciprocal relationship with measles, a leading cause of death among young children. Iodine deficiency leads to still births or miscarriages. Worldwide, an estimated 45 percent of deaths of children under age 5 are linked to malnutrition3. About 3 million children under the age of five die every year due to malnutrition-related causes4. 1 WHO 2007, Global Database on Vitamin A Deficiency. http://www.who.int/vmnis/vitamina/data/database/countries/lso vita.pdf, visited 24 March 2018, 17.00 hours. 2Global Nutrition Report 2017 3 1 Bhutta, Z et al. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet 382: 452-477. 4 Investing In Nutrition The Foundation For Development, An Investment Framework To Reach The Global Nutrition Targets, Shekar M, Kakietek J, D'Alimonte M, Walters D, Rogers H, Dayton Eberwein J, Soe-Lin S, Hecht R, Lesotho Food and Nutrition Strategy and Action Plan Page 3 Disabilities Vitamin A deficiency in preschool age children compromises their immunity system and leads to preventable blindness. On the other hand, apart from causing still births, iodine deficiency causes goitre (swelling of thyroid gland), impairs cognitive development and capacity leading to mental retardation in severe cases, including cretinism. Iodine deficiency can also lead to deaf- mutism. Reduced brain development and school performance About 17.7% of all repetitions in schools are associated with stunting, and stunted children achieve 3.6 years less in school (COHA Lesotho, 2016). These consequences are inextricably linked to and compound those of micro-nutrient deficiencies. Micronutrient deficiencies reduce cognitive and psychomotor development, and reduce the ability to concentrate and scholastic performance. Increase in non-communicable diseases Malnutrition manifests in people who carry too much weight, or who are prone to chronic illnesses due to high blood content of sugar, salt, and cholesterol, or people with diet related cancers, high blood pressure and hypertension. Malnutrition and diet are now the largest risk factors responsible for the global burden of disease (Forouzanfar et al. 2015). Diet-related NCDs are now the major cause of death among adult men and women, especially above the age of 40 years. Reduction in labour force It is estimated that child mortality associated with undernutrition has reduced Lesotho’s work force by 7.2% (COHA Lesotho 2016). Stunted adult men and women have a short stature, and this compromises their physical work potential. At the same time anaemia prevalence in adult women and men causes fatigue that reduces physical activity. Retarded economic growth The annual costs associated with child under-nutrition (through impact on the labour supply and educational attainment) are approximately 1.9 billion Maluti or 7.13% of the GDP5. Globally, analysts estimate that malnutrition can retard growth in GDP by even up to 10 percent per annum (Horton and Steckel 2013; IFPRI 2015a; World Economics 2016). Slowed pace of achievement of Sustainable Development Goals Malnutrition will slow down the achievement of 12 out of the 17 Sustainable Development Goals. These SDGs cannot be achieved until Lesotho addresses food and nutrition challenges undermining opportunities of the poorest and most vulnerable people. 1.4 The Major Factors Contributing to Food and Nutrition Insecurity 1.4.1 Diseases and poor health care A major causal factor for high malnutrition rates in Lesotho is the high prevalence of infectious diseases such as diarrhoea, HIV and TB and poor health care. The report on the Cost of Hunger Study in Africa (COHA) Lesotho 2016, states that less than half (42%) of the 33.2% of stunted children under the age of 5 years in Lesotho, receive proper health attention, and most of the health costs associated with undernutrition occur before the child turns 1 year old. 1.4.2 Poor access to improved water sources and sanitation facilities and hygiene practices Prevalence of diarrhoea, associated with compromised WASH practices is a major contributor to stunting, and the use of zinc supplements to manage diarrhoea is hardly practiced, as less than 5Government of Lesotho, African Union, NEPAD, UNDP, WFP, UNICEF, Cost of Hunger in Africa, Lesotho Lesotho Food and Nutrition Strategy and Action Plan Page 4 1% of the 12% of children who suffer from diarrhoea receive zinc supplements (LDHS, 2014). Yet zinc supplementation can decrease the number and duration of diarrheal episodes. A combination of contaminated water, poor hygiene and inadequate sanitation practices is the main cause of diarrhoea. About 22.8 percent of rural people do not have access to an improved water source and a majority of them do not treat their drinking water. Nationally, only 11.8 percent of households use an appropriate water treatment method before drinking (LDHS 2014). 1.4.3 Chronic food insecurity Inadequate food intake (meal frequency), limited diversity of diets and the low intake of micronutrients, in particular, are major drivers of chronic malnutrition and micronutrient deficiencies in Lesotho. Nine out of ten children in the age-group 6-23 months does not have an adequate diet. Intake of micro-nutrients is in particular very low. About 39.2 percent of children 6- 23 months of age are not fed the recommended minimum number of times per day according to their age (LDHS 2014). Food insecurity (market scarcity, high cost and low household income to purchase) is a major factor affecting the ability of households to secure adequate food to meet their needs. 1.4.4 Low levels of education Low educational level of the mother, partly attributed to school dropouts associated with early marriages and teenage pregnancies and orphan-hood is also a major contributor. In Lesotho, available research evidence shows that children of mothers with secondary education are 50% less likely to be stunted (LDHS, 2014). Better educated mothers and caregivers of children have more information sources and mental capacity to comprehend nutrition messages, have more income and exercise better nutrition purchasing choices. They are more likely to feed themselves and their children better (balanced diet and more frequently). 1.4.5 Household poverty Low household incomes lock households in a vicious circle of poverty, low investment and underdevelopment, which is contributing to low food self-sufficiency, inability to pay for education, inadequate purchasing power to interact with food markets and secure their food needs, failure to improve their access to health services, improved water sources and sanitation. Poor households are less likely to afford soap much needed for good hygiene practices and prevention of diarrhoea. In 2014, the LDHS observed that children under the age of 5 years who came from households in the lowest wealth quintile were 3.5 times more likely to be stunted than those in the wealthiest quintile. The former were also 5 times more likely to suffer from acute malnutrition than those from the wealthiest households, but malnutrition was also found in some of the wealthiest households thus showing that wealth alone is not a sufficient condition for eradication of malnutrition. 1.4.6 Weak coordination of multi-sectoral approach to food and nutrition security In addition to the above, recent studies also documented the weak coordination of sectors to provide an integrated response to this multi-dimensional problem (Lesotho Multi-sectoral Nutrition Governance Capacity Assessment Report, 2018). The structural and organizational challenges include:  Weak coordination, integration and harmonisation of the multi-sectoral approach to planning, implementation, and monitoring of nutrition interventions;  Low priority given to nutrition resulting in inadequate funding of nutrition and shortage of operational resources both centrally and at decentralised level;  Limited placement of available skilled staff in strategic positions for nutrition implementation and governance;  overlapping roles and responsibilities of nutrition staff in different sectors resulting in inefficiencies and gaps;  There are inadequate systems for procurement and supply of nutrition materials including for food and micronutrient supplementation; Lesotho Food and Nutrition Strategy and Action Plan Page 5  Food fortification is also not streamlined and standards are not set;  The country’s mountainous terrain and lack of road infrastructure limits livelihood options, accessibility of health, water, sanitation and hygiene services and the extent to which equity in service use can be achieved (Lesotho Food and Nutrition Policy, 2016).6 1.5 Efforts to address food and nutrition challenges in Lesotho Lesotho is rich with dedicated past and on-going efforts to address nutrition and there is success since malnutrition (especially chronic) is declining. Infant and Young Child Feeding has been included in the Health Sector Strategic Plan 2012/13-2016/17. Interventions have focused on training of health personnel utilizing the IYCF Guidelines adapted from WHO 2010 and 2016 versions; exclusive breastfeeding for the first 6 months and assisting the HIV-positive mother to make informed choices on duration of breastfeeding, adequate and safe infant and young child feeding including supporting the mother or caregiver of an HIV exposed infant to carry out a feasible feeding option based on their situation7. The then Ministry of Health and Social Welfare in 2012 implemented a pilot programme on comprehensive care of pregnant women from the community to the health centre level, linking key primary care services to ANC and facility-based delivery in the Mountains Region8. Voluntary industrial fortification of food is being practised by 2 food producers. Lesotho benefits from the universal salt iodisation on its imported salt and has since late 1990s actively educated the population on the benefits and use of iodised salt and introduced the salt iodisation regulation in 1999. Studies on the level of salt iodisation are outdated, but have shown that the level varies and very low levels of iodine were generally found in the salt. (Sebotsa ML, Adjei R. 2002)9. The Demographic Health Survey of 2014 also confirmed that 7% of households do not use iodised/iodated salt. Lesotho imports all its salt but the monitoring of the salt is however weak and recent observations are that the prevalence of goitre is again rising. Vitamin A routine supplementation is done through public health facilities (the Ministry of Health and CHAL) and mop-up campaigns during Child Health Days. The Ministry of Agriculture and Food Security has embarked on efforts to strengthen the food value chain towards achieving sustainable diversification and commercialism with an emphasis on developing integrated value chains10. This entails building effective agricultural support institutions, improving risk management in the sector and reducing stock theft. The livestock subsector – in particular wool and mohair – has been singled out as one of the country’s most important value chains, and possesses considerable potential to contribute to economic growth and poverty reduction (FAO, Lesotho Website, 2017). Government together with the World Bank and International Fund for Agriculture Development (IFAD) has been implementing from 2012 to-date a Smallholder Agricultural Development Programme (SADP) to support smallholder farmers in exploiting opportunities and increasing productivity, as well as diversifying into market-oriented agriculture. The programme focuses on four selected districts with high agricultural potential (Botha-Bothe, Leribe, Berea and Mafeteng), where projects are underway in irrigated vegetable production, wool and mohair, dairy, piggery and poultry hatcheries, among others. 6Lesotho Food and Nutrition Policy 2016 7IYCF PMTCT 2016. Training materials on the WHO IYCF Guidelines 2016. 8 Hind Satti, Sophie Motsamai, Palesa Chetane, Leshoboro Marumo, Donna J. Barry, Jennifer Riley, Megan M. McLaughlin, Kwonjune J. Seung, Joia S. Mukhurjee, 2012. Comprehensive Approach to Improving Maternal Health and Achieving MDG 5: Report from the Mountains of Lesotho. 9 Sebotsa ML, Adjei R. 2002. The evaluation of the iodine content of table salt in Lesotho. African Journal of Health Sciences, 2002 Jul-Dec; 9(3-4):139-45. 10http://www.lesothoreview.com/agriculture-2015.php (visited 5/12/2017: 14.30 hours). Lesotho Food and Nutrition Strategy and Action Plan Page 6 In response to the food insecurity crisis in Lesotho, the MAFS with support from FAO, have been implementing a three-year programme to assist vulnerable households with agricultural inputs and know-how on agricultural technologies, helping communities to adapt to climate change and build their resilience to better withstand future shocks. The Emergency and Resilience Programme (ERP) provided input support and capacity development on conservation agriculture, home gardening and nutrition, targeting communities, lead farmers and extension services11. Boyed by positive results Government has continued to commit itself to subsidising agriculture and irrigation revitalisation until local farmers are adequately developed and local food reserves stocked with ample grain crops. Lesotho seeks to reduce its reliance on imports which satisfy more than 91 percent of its annual demand for sorghum and wheat. Block farming and conservation agriculture have been promoted to intensify production and simplify management, on one hand, and conserve soil structure, fertility and water on the other, leading to higher yields, of high-quality crops that can be sold commercially. Significant efforts have been invested in improving breeds of various stock (especially small stock), addressing stock theft, improving animal nutrition, controlling outbreaks of animal diseases and providing infrastructure to prevent and control the transmission of disease, with special focus being placed on production of wool and mohair, poultry, piggery, dairy and beef (Joint Agri-Business and Department of Agriculture Forum for Africa (JADAFA), 2014). The Government of Lesotho developed a National Social Protection Strategy in 2014 and rolled out a package that includes a universal infant grant per infant under 2 years, child grant to all extremely poor households with children, national seasonal employment guarantee scheme to offer public works to the poor of working age, universal old-age pension to those 68 years and above, disability grant to all those with severe disabilities with transfer value indexed to inflation, and a discretionary public assistance grant to all requiring short-term reactive temporary support. The Government has been implementing a National Sanitation Programme for decades, and has introduced a system of constructing latrines. A number of capacity building initiatives have also been implemented on nutrition governance and implementation by the Ministry of Health with financial and technical support from UN and other development partners. The target groups varied by type of training, with health workers, FNCO staff, Ministry of Education and Training officers, and Ministry of Agriculture staff, being reached by different combinations of the above training courses. Lesotho has also undertaken a series of water sector reforms and reorganisation to strengthen regulatory, service provision, coordination and decentralisation. It revised the national water policy in 2007 and the water act in 2008 as part of efforts to accelerate efforts to achieve universal access to water access by 2020. In addition, with support from the AfDB, the Government has been implementing a four year Rural Water Supply and Sanitation Project for the Lowlands (December 2013 – December 2017). The project promoted the use of existing water resources to increase the coverage and extend the benefit to the rural population. It also promoted donor coordination in the water sector. 1.6 Challenges The absence of an explicit policy, standards and incentives for the private sector hampers on- going voluntary food fortification initiatives by the private sector. Lesotho imports all its salt but the monitoring of the salt is however weak and recent observations are that the prevalence of goitre is again rising. 11 Ibid. Lesotho Food and Nutrition Strategy and Action Plan Page 7 Studies on the level of salt iodisation are outdated, but have shown that the level varies and very low levels of iodine were generally found in the salt (Sebotsa ML, Adjei R. 2002)12. The Demographic Health Survey of 2014 also confirmed that 7% of households do not use iodised salt. According to the Lesotho DHS 2014, coverage of Vitamin A is inadequate as only six out of ten children (61%) aged 6-59 months received a vitamin A supplement and one in five (22%) received deworming medication in the six months preceding the survey. The programme was challenged by adverse reporting of adverse events and indicated the need for more intensive education on deworming and supplementation coupled with child vaccination. Key challenges with the capacity building initiatives implemented by MoH, FNCO, the UN and development partners include that: 1) information from the training is not shared by the trainees and they work in silos; 2) on-the job training and coaching is effective; 3) training with minimum mentoring is not very effective; With respect to sanitation, education of users and uptake of available technologies for improving sanitation has been weak. Concerns have also been raised on the need to strike a balance between government budget allocation to promoting the construction of improved sanitation and that allocated to improving household access to safe water. 1.7 Lessons learned A major lesson learnt from the past interventions promoting exclusive breastfeeding is that the uptake of advice given through counselling of mothers is hampered by the pressure from family and community members to give the baby other liquids (Ministry of Health, Nutrition Unit, 2017). At the same time introducing formula feeding is constrained by poor hygiene standards, over- dilution of the formula, and the high cost of the formula vis-à-vis the low income levels of poor households. Furthermore, past experience has demonstrated that combining group education and individual counselling works in promoting the recommended IYCF practices for the general population. Building the capacity of health care workers in infant feeding counselling should be complemented with the involvement of Community Health Workers, fathers and families. Integration of PMTCT services with access to ART also needs to be prioritised. The pilot programme on comprehensive care of pregnant women which is currently undergoing has shown that it is possible to achieve dramatic improvements in the utilisation of maternal health services and facility-based delivery by strengthening human resource capacity, implementing active follow-up in the community and de-incentivising home-based delivery (Hind Satti, et. al., 2012)13. Global evidence shows the returns to investment in micronutrient interventions are 8030 times the cost (Horton S. et al. 200914, Scaling-Up Nutrition: What Will it Cost?). Home fortification of complementary foods with vitamins and minerals has been proven to be an effective public health intervention. The World Bank’s project review of July 2014 found the SADP Competitive Grants awarded to registered associations and businesses working. 12 Sebotsa ML, Adjei R. 2002. The evaluation of the iodine content of table salt in Lesotho. African Journal of Health Sciences, 2002 Jul-Dec; 9(3-4):139-45. 13 Hind Satti, Sophie Motsamai, Palesa Chetane, Leshoboro Marumo, Donna J. Barry, Jennifer Riley, Megan M. McLaughlin, Kwonjune J. Seung, Joia S. Mukhurjee, 2012. Comprehensive Approach to Improving Maternal Health and Achieving MDG 5: Report from the Mountains of Lesotho. 14Horton S. et al. 2009, Scaling-Up Nutrition: What Will it Cost? Lesotho Food and Nutrition Strategy and Action Plan Page 8 The ERP has been an effective mechanism to transfer knowledge and skills to extension officers, lead farmers, farming households, local leaders, and teachers from primary and secondary schools. This holistic approach to capacity building works in improving resilience to shocks. Government’s subsidy for summer cropping has been effective in increasing food production as it topped up purchasing power for inputs that are unaffordable to the majority of the poor farming households. Irrigation rehabilitation and development is popular and works as it creates income earning opportunities year-round and uses appropriate gravity fed water technology with little maintenance requirements. A comprehensive and well-designed national social protection system incorporating social care services is a sound economic investment. Predictable social transfers at household level provide more than just welfare and can positively improve the livelihoods and productivity of the poor by encouraging them to enter the labour market or embark on higher risk yet higher return investments. A social cash transfer can boost household purchasing poor, alleviate food shortages and contribute to dietary diversity which are all important for nutrition and health of the poor. The national sanitation programme has demonstrated that self-financing of latrine construction is feasible for many households. Government’s sustained support is important. Small private companies can make a living from the construction of sanitation facilities. A key lesson from training initiatives on nutrition government and delivery is that training should be differentiated or targeted by cadre in order to be more relevant and effective. In addition, training conducted without guidelines or reference materials, and with limited sector coordination reduces the benefit of such trainings. Sanitation promotion through radio programmes works when emphasising two key messages (improved health and improved social status) in the promotion of improved sanitation. Strong ownership of WASH projects by beneficiaries is crucial for smooth execution and sustainability of outcomes, hence WASH projects should use participatory methods and build community level structures for operation, maintenance and replacement. 1.8 High level political will and commitment to address food and nutrition security in Lesotho At the highest level of government, several initiatives have been undertaken by the political leadership of the country to raise the profile of nutrition. A national policy on food and nutrition was endorsed by Government in 2016. Furthermore, Lesotho is advantaged by the role of His Majesty as AU Champion of Nutrition and FAO Ambassador of Nutrition (Globally). Her Majesty the Queen is the patron for Breastfeeding and nutrition of children under 2 years age (0-23 Months) in Lesotho. This should be a catalyst and opportunity to the country in upscaling of nutrition. 1.9 Rationale for a new food and nutrition strategy and action plan Despite the existence of a number of food and nutrition programmes and the implementation of several interventions, the nutritional status of the population, especially of vulnerable groups (young children, pregnant and lactating mothers, adolescents and youth, orphans and the elderly) remains unsatisfactory and below international standards. In particular, chronic malnutrition (stunting) remains persistently prevalent in Lesotho, with devastating consequences. There is a clear need to address the direct, underlying and basic causes of malnutrition using proven high impact interventions that are implemented at scale and the desired level of quality. Lesotho Food and Nutrition Strategy and Action Plan Page 9 Lesotho needs a well-defined medium-term national strategy to implement and scale-up proven and innovative multi-sectoral food and nutrition interventions in a cost-effective manner and within an enabling environment for improved nutrition. Such a strategy will improve coordination of efforts, clarify roles and responsibilities of actors, capacitate actors, reduce duplication of assistance, expand coverage of the available finite resources, harmonise service packages, fill intervention gaps, better coordinate resource mobilisation and allocation to food and nutrition, and strengthen management of the development results. It will also define short, medium, and long-term priorities as regards food and nutrition security. 1.10 The formulation process and content The National Food and Nutrition Strategy and Action Plan has been developed by a multi- sectoral team, led by the Food and Nutrition Coordinating Office, with technical and financial support from the Renewed Efforts Against Child Hunger and Under-Nutrition (REACH) funded by Irish Aid and the UN Network in Lesotho. The process involved six steps starting with a process launch workshop attended by more than 60 participants drawn from the key government sector ministries, the UN Network, NGOs, Research Institutions and members of the Academia. The process launch was used as a platform to discuss and reach consensus on the consultation methodology, stakeholders to be consulted, the tools to be used for the interviews, the timeline for all activities and the outputs. Five consultation teams were also formed from the sectors, according to thematic areas that had been identified by a multi-sectoral nutrition overview (MNO) as areas where strategic focus of the strategy should be directed. The second step was the consultation of national stakeholders grouped into 5 thematic areas, namely: 1) Health and WASH; 2) Food Value Chain; 3) Social Protection; 4) Behaviour Change Communication; and 5) Nutrition Governance. Each thematic area was assigned a multi-sectoral team to carryout consultations and document the findings using a harmonised template for reporting. At least 40 institutions and 60 key informants were consulted at national level across the five themes. This phase culminated in the convening of a national workshop to synthesise key messages from the national stakeholders which would inform the third phase of the consultations, that is district consultations. The third phase consisted of district and community consultations. These were carried out through two-day district level multi-sectoral consultation workshops and four community level focus group discussions with 10-15 people per group. These were drawn from those participating, benefitting or residing in areas where projects are underway to implement core nutrition actions that were identified for Lesotho. Key informant interviews were also held with local leaders, and the district administration officials to solicit their views. The Core Nutrition Actions were identified based on the evidence on food and nutrition security in Lesotho gathered through the MNO. Their selection was informed by global evidence on what works, which was availed by the REACH Secretariat (WFP Rome) in the form of a Compendium of Core Nutrition Actions being advocated for scale-up to reduce malnutrition globally. The district and community level consultations were held in 4 districts selected on the basis of the prevailing food and nutrition security status (high and low prevalence of malnutrition), agro-ecological zones (to cover mountainous, foothills and lowlands), existence of projects implementing one or more core nutrition actions, and partners to facilitate the visit to the project sites. In the fourth step, a three-day national multi-stakeholder workshop was held to formulate the strategy. It was attended by 45 participants, and these built upon the inputs collected from districts. The fifth step was to draft the narrative part of the strategy detailing the background, situational analysis, the client and stakeholder analysis, the vision, mission, key result areas, goals, strategies, assumptions and risks, implementation plan and the results framework. The drafting exercise was done by a multi-sectoral team representing the key sector ministries, the UN Network, NGOs, and FNCO. Lesotho Food and Nutrition Strategy and Action Plan Page 10 An M&E Formulation Workshop was then held to discuss the impact and outcome plans, indicators, data sources, baselines, annual performance targets and allowable thresholds for the five years of implementation. Finally the Strategy and Action Plan was costed in a five-day workshop by a multi-sectoral team of planners and budget officers using results-based budgeting, and the US Dollar as reference currency. 2 VISION, MISSION AND PRINCIPLES 2.1 Vision A well-nourished, healthy and productive nation. 2.2 Mission To implement and scale-up proven and innovative multi-sectoral nutrition interventions. 2.3 Guiding Principles The development and the proposed approach to implementation of the strategy are guided by 6 principles, listed hereunder. Guiding Principle 1: Food and nutrition as a basic human right: Government of Lesotho shall act in accordance with a commitment to uphold food and nutrition equity and rights of all citizens with particular emphasis on vulnerable groups, including orphans, people living with disability, women, and children. Guiding Principle 2: Multi-sectoral Approach shall be a vital model/technique which shall facilitate cordial planning among government stakeholders, NGOs, UN-Agencies, private sector, academia and media in order to reduce duplication of efforts and encourage sharing of resources so as to achieve the best nutrition results through broader coverage and assist other nutrition related programmes to achieve greater results while at the same time demonstrating positive potential impact. Guiding Principle 3: Alignment with regional, continental and global commitments: The Food and Nutrition Strategy shall align itself to strategic local initiatives as well as regional, continental and international nutrition standards, guidelines and conventions. Guiding Principle 4: Good governance: Implementation of the Strategy shall be guided by principles of good governance and shall include oversight from national, district and local government structures. Resource allocation for nutrition and its use shall be monitored at all levels. Effective performance management systems shall be implemented to reward best performance through increased resources. Good finance and management systems shall be adopted to ensure effective and efficient use of resources. Effective monitoring and evaluation systems shall be adopted to ensure accountability and transparency. Guiding Principle 5: Community participation: Communities shall be empowered to express their felt needs and participate in planning and prioritisation of their needs given the limited Lesotho Food and Nutrition Strategy and Action Plan Page 11 resources. They shall be fully engaged in the implementation of the food and nutrition projects, which will promote community ownership hence sustainability and resilience. Guiding Principle 6: Life-cycle approach: A life cycle approach shall be used to ensure that nutritional needs of different age groups and stages of life are addressed appropriately, save lives and reduce inequities, with a focus on targeting those most in need – the poor, hard-to- reach, vulnerable, most vulnerable and marginalized communities and individuals. Guiding Principle 6: Gender equality: Gender sensitivity and responsiveness shall be applied in food and nutrition service planning and implementation by ensuring that gender considerations and the needs of all vulnerable groups are integral to all components of the strategy. 3 TERMS OF REFERENCE AND FUNCTIONS OF GOVERNMENT AGENCIES WITH NUTRITION IMPLEMENTATION MANDATES 3.1 Terms of Reference There are four key ministries with specific mandates on food and nutrition. The Ministry of Health’s mandate is to ensure that maternal and child health and nutrition services are prioritized and implemented in the health sector. The goal of the Ministry of Agriculture is to improve the food and nutrition security and combat malnutrition through food-based interventions and improve the quality of life of the population. The ministry plays a central role in nutrition advocacy and prevention activities. The Ministry of Education and Training is mandated to ensure that nutrition education is included into the school curricula and effectively implemented in all education institutions as well to enhance the performance of children through the school feeding program. The goal of Ministry of Social Development is to improve the quality of life of all Basotho through interventions that address poverty, deprivation, vulnerability and inequality in a comprehensive and holistic manner. The table below illustrates the policies and plans which guide the ministries to perform their mandates. 3.2 Overall Functions The MOH implements the following activities:  nutrition education;  nutrition assessment, care and support;  food supplementation for TB, HIV and AIDS patients;  growth monitoring and promotion;  IYCF programmes;  micronutrient supplementation;  conducts in-service training of health personnel in nutrition and dietetics;  assist in the nutrition components of Safe Motherhood and Integrated Management of Childhood Illnesses (IMCI);  provides nutrition education, therapeutic food and following-up cases discharged from hospitals, as well as food management services in hospitals;  Manage diet-related non-communicable diseases; Lesotho Food and Nutrition Strategy and Action Plan Page 12  Carryout water, sanitation and hygiene campaigns and ensure adherence to food safety standards and programmes for disease and infection prevention and control in public places, including schools and institutions, and in households;  the Ministry provides technical guidance on health issues to other ministries; and  through its HMIS system, generates and monitors nutrition indicators. The Ministry of Agriculture performs the following tasks:  Undertake activities aimed at creating and promoting awareness, and educating the public on general nutrition, nutrition in HIV and AIDS treatment, care and support and improved livelihoods;  Monitoring and evaluation of nutrition and home economics projects;  Liaising and exchanging ideas with other institutions and NGOs that are involved in nutrition and home economics, and ensuring that there are trained nutrition and home economics personnel at all levels of service delivery;  Pursuing and conducting food and nutrition research and disseminates research findings to the public in order to improve nutrition awareness;  Empowering farmers to creating innovative projects that will add value to their products, so as to compete on the market for improved quality and enhanced earnings;  Empowering youth in rural areas with entrepreneurship skills that will motivate them to be involved in agricultural-based enterprises for increased productivity and creation of employment;  Empowering women in nutrition-related livelihood interventions, this being one of the strengths of the nutrition department; and  Ensuring adherence to phytosanitary standards. Ministry of Education and Training carries out the following activities:  Supporting local agricultural production for school meals.  In partnership with MOH providing PHC services to schools. Ministry of Social Development has the following mandate, among other responsibilities:  Leading and facilitates the provision of sustainable development services that are universally accessible to vulnerable groups in Lesotho through implementation of such programmes as public assistance, child grants programme, OVC bursaries and community development.  Reducing the economic and social vulnerability of poor, vulnerable and marginalised groups and increases their inclusion in social and economic activities.  Assisting with the acquisition of food and increase purchasing power to ensure nutritional well-being of beneficiaries. Lesotho Food and Nutrition Strategy and Action Plan Page 13 Lesotho Food and Nutrition Strategy and Action Plan Page 14 4 THE FOOD AND NUTRITION SITUATION AND KEY FEATURES OF THE OPERATING ENVIRONMENT 4.1 Nutrition Situation Lesotho faces a double burden of communicable and non-communicable diseases due to chronic malnutrition. According to the Annual Joint Review (AJR) report 2015/2016, of the major causes of admissions among children under five years of age (<5 years), malnutrition was the fourth top cause and third to fifth (differ by gender) cause for admission among children 6-12 years of age. Malnutrition was the top cause of death among female children under five years and second cause for males of the same age (AJR report, 2015/2016). This document will use the lifecycle approach to highlight trends in nutrition over the last 15 years or more. Data is available for most of the key nutrition indicators from conception, infancy, childhood, adolescence and other population groups and will especially be highlighted during the first 1000 days of life for effective interventions against stunting. The table 1 below depicts the current status of Lesotho, global and national targets for 2025. Table 1: World Health Assembly and Lesotho Targets for 2025 Contrasted with Lesotho Current Status Indicator WHA Targets 2025 Lesotho Current Status 2016 (from 2009) 2025 target for Lesotho Stunting 40% reduction in children Under 5 years of age 33% (from 39%) 23.4 % Anaemia 50% reduction in women of child bearing age 27% (from 26%) 13.5% Low birth weight 30% reduction 10.4% (from 9.3%) 7.3% Childhood Overweight No increase 7% (from 7.2%) <7% Exclusive Breastfeeding 50% increase in children under 6 months 67% (from 54%) 100% Wasting Reduced & maintained at <5% 2.8% (from 3.8%) <5% Source: WHO Ambition and Action Strategy, 2016-2025. 4.1.1 Women of child bearing age (15-49 years) In Lesotho Child bearing starts early with 19% of 15-19 years already having a first child. The total fertility rate has been stagnant between the years 2009 to 2014, estimated at 3.3% though Lesotho Food and Nutrition Strategy and Action Plan Page 15 lower in urban settings at 2.3% compared to 3.9% in rural settings. Furthermore 15% of women aged 20 - 49 years had their first birth at 15 years of age (LDHS, 2014). Children born to adolescents are more likely to have low birth weight and to become stunted or wasted. In addition to ensuring that mothers are well nourished before and during pregnancy, delaying the age of first pregnancy is key to reducing malnutrition during the first 1000 days. The rates of stunting is more than 2 times higher among children whose mothers have only attained primary education compared to children whose mothers have attained higher levels of education (LDHS, 2014). Therefore, keeping girls longer in school delays the age at which a woman will give birth to her first child and will therefore help to prevent malnutrition. Over a third of women have begun childbearing by age of 19 (LDHS, 2014). Inadequate intra-uterine nutrition is proven to result in low-birth weight (small for gestational age) and poor development of central nervous system in infants (Zimmet et al, 2014) .The rate of malnutrition among pregnant women remains unknown, but low-birth weight (new-borns weighing < 2.5kg), which serves as a proxy for maternal nutrition status currently stands at 10.4% (LDHS, 2014). According to the LDHS, 2014, the prevalence of low birth weight is higher in adolescent mothers which increased from 8.9% (2009) to 13.8% (2014). This is coupled with high rates of anaemia (haemoglobin <12g/dL in non-pregnant women, < 11g/dL in pregnant women) among women of child bearing age 46.5% (LDHS, 2014). While over a quarter of women in the country have some form of anaemia (LDHS, 2014). Vitamin A deficiency in pregnant women Though the prevalence of vitamin A deficiency is below the critical threshold, it remains significant in women of child-bearing age. Night blindness is a subclinical sign and proxy for Vitamin A deficiency, though measurement is subjective. Measuring retinol levels in blood is a biochemical indicator whereby levels <0.70µmol/L constitute Vitamin A deficiency (WHO Global Database on Vitamin A Deficiency: Global prevalence of Vitamin A in populations at risk, 1995- 2005). Figure 1 below shows the rate of Vitamin A deficiency among pregnant women. Figure 1: Vitamin A deficiency among pregnant women. 4.1.2 Infants (0-6 months) Colostrum is contained in the mother’s first milk, just after birth, and it contributes to the prevention of infections and is extremely rich in nutrients (LDHS, 2014). Early initiation to breastfeeding promotes good lactation; it also presents a series of benefits for post-partum mothers (reduces breast and ovarian cancers) (LDHS, 2014). Figure 2 indicates trends of early initiation to breastfeeding from 2004 to 2014, while figure 3 illustrates breastfeeding status for under 6 months. In Lesotho, 65% of newly born children are initiated to breastfeeding within the first hour of birth and 66.9% of children aged between 0 to 6 months are exclusively breastfed (LDHS, 2014). Lesotho Food and Nutrition Strategy and Action Plan Page 16 Figure 2: Early Initiating of Breastfeeding within the First Hour of Birth Figure 3: Breastfeeding Status Under 6 Months 4.1.3 Children (6-23months) While only 11.3% of children 6-23 months are fed according to appropriate complementary feeding practices. With a high anaemia prevalence among children under five years of 51% (2014, LDHS), fewer than half of all children 6-23 months (40.5%) consuming iron rich foods and only 60.5% of children 6-23 months consuming vitamin A rich foods, micronutrient malnutrition remains a serious concern for Lesotho. In light of this, deworming also remains a priority if micronutrient malnutrition is to be reduced. Figure 4 shows feeding practices among children aged 6 to 23 months. Lesotho Food and Nutrition Strategy and Action Plan Page 17 Figure 4: Infant and Young Child Feeding Practices 4.1.4 Children under Five (U5) years (< 5 years) Improved nutritional status among children under five years could be achieved through enhanced exclusive breastfeeding for the first 6 months, timely introduction of complementary foods and micronutrients supplementation. The net effects of these interventions could result in reduced stunting, wasting, underweight, anaemia, obesity and ultimately infant mortality (Kenya Strategy, 20172/17). Trends in malnutrition indicate that chronic and acute malnutrition in children under five years have decreased since 2004, however stunting (HAZ<-2SD) still remains high at 33.2% (LDHS, 2014). The prevalence of severe acute malnutrition (severe wasting) (WHZ <-3SD) among children under five years old has declined from 1.8% to 0.6% (LDHS, 2014). Figure 1 below illustrates the trends of malnutrition in children since 1992 to 2014. Lesotho Food and Nutrition Strategy and Action Plan Page 18 33 45.4 30.7 38.2 41.7 39.2 33.2 15.8 17.9 15.4 19.8 13.8 13.2 10.3 2.4 5.4 3.2 4.3 2.3 3.8 2.8 0 5 10 15 20 25 30 35 40 45 50 1992 NUT SURVEY 2000 MICS 2002 NUT SURVEY 2004 LDHS 2007 NUT SURVEY 2009LDHS 2014 LDHS Stunting Underweight Wasting Figure 5. Malnutrition trends in Lesotho based on various surveys (1992-2014) Sources: i) MICS, 1992; ii) Nutrition Surveys, 2007; and iii) LDHS, 2014. Anaemia in Children U5 The prevalence of anaemia (haemoglobin<11g/dL) in children under five years has remained a critical public health problem, and stands at 50.8%). Half of all children have some form of anaemia Deworming of children is one of the intervention to combat anaemia as one of the causes of anaemia include parasitic infections (helminths and schistosomiasis). On average, one in five children in Lesotho receive deworming tablets/medication, though rates are lower in Quthing and Qacha’s Nek (LDHS, 2014). Vitamin A deficiency in Children U5 Vitamin A deficiency can compromise immunity and lead to preventable blindness, increased risk of mortality, and reciprocal relationship with measles, as well as a leading cause of death among young children. Vitamin A deficiency (serum retinol value of vitamin A of ≤ 0.7µmol/L (≤ 20µg/L) among children under five years old is at 32.7%, as illustrated by figure 6 below, and remains a severe public health problem among children (LDHS, 2014). Figure 6: Vitamin A deficiency in pre-school age children Lesotho Food and Nutrition Strategy and Action Plan Page 19 Iodine deficiency in children U5 Measuring urinary Iodine levels is a biochemical indicator whereby low median urinary levels (<100µg/L) indicate deficiency. Iodine deficiency status in children between the ages of 6-11 years old is at 214.7 µg/L (Urinary Iodine Excretion Survey). In addition, one fifth of all school- aged children had iodine deficiency in 2002 (WHO Vitamin and Mineral Information System: Global Database Iodine Deficiency - Lesotho). Overweight in Children U5 Recently childhood obesity is recognized as an emerging nutritional burden in children affecting both poor and rich populations. Overweight and obesity prevalence in children younger than 5 years is becoming an increasingly important contributor to adult obesity, diabetes, and other NCDs. The trends in early childhood overweight are probably a consequence of changes in dietary patterns (high energy intake, consumption of sugar-sweetened high fructose corn syrup sodas and fruit drinks, a low intake of fibre) and increasing sedentary activity (more time is spent using computers or watching television). If these trends are not reversed, childhood overweight and obesity will have vast implications, not only for future health-care expenditures but also for the overall development of the country. Therefore early recognition of excessive weight gain to linear growth (BMI-for-age) for this group is of paramount importance to ensure good health in childhood and later during adulthood. (WHO &UNICEF, 2015). Overweight (WHZ >+2SD) in children under five years has remained around 7%, since 2009 as depicted in figure 7 below , showing a slight increase (LDHS, 2014). Figure 7: Prevalence of overweight status in children under the age of five years Lesotho Food and Nutrition Strategy and Action Plan Page 20 4.1.5 Adolescents (10-24 years) Improving nutrition in schools and other institutions will contribute to the overall national efforts of promoting optimal nutrition among this group. Health problems among youths and adolescents in Lesotho are mostly of a sexual and reproductive health nature. Sexual practices among adolescents and young people, include multiple sexual partners and age mixing (RMNCAH & N Strategy, 2017-2022). According to LDHS 2014, 5% of young women and 23% of young men reported having multiple sexual partners. In Lesotho, 8% of young women aged 15-19 had sexual intercourse with a man who is 10 or more years older and one percent (1%) of young men aged 15-19 reported having a partner who is 10 or more years older. This practice can contribute to the spread of HIV and other STIs because if a younger, uninfected partner has sex with an older, infected partner, this can introduce the virus into a younger, uninfected cohort. Prevalence of HIV among adolescents and youth is very high and increasing with females more infected than males (RMNCAH & N Strategy, 20167-2022). Table 2 below shows trends of HIV prevalence among youths and adolescents. Table 2: Trends of HIV prevalence among youths and adolescents Female Male Age LDHS 2009 LDHS 2014 Age LDHS 2009 LDHS 2014 15-19 4.1 5.4 15 -19 2.9 4.8 20 - 24 24.1 21.5 20 – 24 5.9 7.5 25 - 29 35.4 37.5 25 – 29 18.4 17.9 Source: RMCAH&N Strategy, 2017-2022 4.1.6 Young Adults, Adults and Elderly Lesotho like other low-middle income countries is undergoing social and economic changes, which are resulting in increased urbanization with a potentially negative impact on health related behaviours. This increasing urbanization is exposing Basotho to a more sedentary lifestyles and highly processed and unhealthy foods, which are high in refined carbohydrates, saturated and trans-fats, salt and sugars. Evidence from different studies has implicated a role of early-life exposures, maternal diet during pregnancy, post-natal growth, and childhood diet to chronic diseases. Hence improved maternal, infant and young child nutrition lay a foundation for NCDs prevention in a number of different ways (WHO, Nutrition Strategy, 2016-2025). Lesotho Food and Nutrition Strategy and Action Plan Page 21 Overweight and Obesity Overweight and Obesity are defined as excessive fat accumulation that presents a risk to health. Overweight and obesity are major risk factors for a number of chronic diseases including diabetes, cardiovascular diseases and cancers. According to Lesotho STEPS Survey 2012, 41.5% of adults (24.8% males and 58.2% females) are overweight, and 19.9% are obese (7.9% males, 31.9% females). While is shown that there is a high level of overweight among women (45% urban and 42% rural), the rate of overweight is lower for men with 12% (LDHS, 2014). Diabetes Diabetes is among diseases which appear high in the morbidity data in Lesotho, and the cost incurred on the health care of patients with diabetes in primary, secondary and tertiary institutions is subsidized by the Government through MOH (LRFS, 2001). This study identified diabetes as the second most treated diseases in the hospitals, and reported that 1.5% of the population had diabetes. The prevalence rate of diabetes in the the capital city, Maseru was at 1.9% (LRFS, 2001). The study also reported that admission rates for patients with diabetes, who present with either acute or chronic complications were escalating in Lesotho, and were possibly related to lack of compliance, lack of knowledge about the disease, and use of traditional and herbal medicines instead of allopathic medicines prescribed by clinicians (LRFS, 2001). LDHS (2014), only determined knowledge of diabetes, and most females (91%) and males (87%) aged 15-49 years have heard of diabetes, while only 43% and 53% respectively did not know of any symptoms of diabetes. High Blood Pressure The STEPS survey of 2012, identified a significant proportion of people with high blood pressure, and some of them are not on medication. The participants who had raised blood pressure were 31% and this was higher among females (35.6%) compared to males (26.3%). While, according to LDHS (2014), 19% of females and 13% of males aged 15-49 years had hypertension, and 5% of all females and 2% of all males had hypertension and have been controlled with medication. Cancers Cancers constitute a priority public health concern, though there is no national data available on the burden of different cancers. However, guidelines and data collection tools have been developed in view of building the national data base on cancers (Draft RMCAH&N Strategy, 2017-2022). The cervical cancer mortality rate was estimated at 23.2%, and breast cancer at 4.4% (IARC, 2012). The proportion of women of reproductive age ever screened for cervical cancer was at 11% (LDHS, 2014). According to LDHS (2014) only (10%) of females aged 15-49 years have had a clinical exam for breast cancer in the past 12 months. The incidences of cervical cancer in Lesotho has decreased from 66.7% in 2007 to 38.4% in 2012 (International Agency for Research on Cancer- IARC, 2012). 4.2 Overview of the HIV and AIDS Situation In 2017, Lesotho was ranked as the country with the second highest HIV prevalence among people aged 15-49 years at 24.3%; higher among females at 29.7% compared to 19.1% for males. The rate was high among adolescents 15-19 years and higher among girls compared to boys at 3.1% and 7.0% respectively. The prevalence varies by urban-rural divide, age, and gender with women and young female adolescents worse off. The results of the LDHS of 2014 indicate that HIV prevalence among pregnant women in 2013 was 25.9% compared to 24.3% in 2011 and 27.7% in 2009. The prevalence is highest among women 35-39 years, (44%) and is Lesotho Food and Nutrition Strategy and Action Plan Page 22 geographically consistent with the LDHS 2009 data. The analysis of the above data indicates the need to prioritise PMTCT interventions and among adolescents. According to the Modes of Transmission Study the key drivers15 for HIV transmission are a combination of behavioural and structural factors. The living and working conditions which young women and men are exposed to in the mines and factories increase their vulnerabilities to risky sexual behaviours that contribute to HIV infection. The risky sexual behaviour combined with the high reports of sexual and physical violence16, gender and income inequalities and the practice of Multiple and Concurrent Partnerships (MCP)- 7% for women and 27% for men17 - contribute to new infections among these sub population groups. 4.3 An overview of the food security situation According to the Lesotho Vulnerability Assessment Committee (LVAC) Report, Lesotho is generally a food deficient country and for years the country has experienced successive climate shocks such as recurrent droughts, dry spells and floods, natural disasters such as heavy snowfalls with serious consequences on the food security of the population. With regards to food and nutrition security situation, the 2017 Global Hunger Index ranked the country 80 out of 119 countries assessed, with an index score of 24.1 indicating a serious food problem.18. Overall, food security conditions in Lesotho have not been improving and a large part of the population remains exposed to situations of chronic and irreversible food insecurity especially the rural population, which is heavily dependent on subsistence farming and other rural non-farm activities. The Vulnerability Assessment and Analysis Report, 2017 indicated a decrease in food insecure population from 679,437 last year (May 2016) to 224,664 in the current consumption year (2017/18) from the rural settlement while about 82,278 people are estimated to be food insecure within urban settlement countrywide.19 National cereal estimates showed that Lesotho produced 238,362 MT for 2017 harvest compared to 30,959 MT in 2016 as illustrated in Figure 8 below20. In 2015/16, the country experienced the worst drought conditions since 1982, combined with its incapacity to produce enough food for its own consumption needs due to limited amount of suitable arable land and erratic climatic conditions plugged the country into severe food insecurity. This led to more than 30 percent decrease in cereal production which was already on a downward trajectory. As a result Lesotho continues to rely heavily on imports from the neighbouring South Africa which is more than 70 percent of its food basket. It is also argued that a substantial amount of all food calories grown per year are lost or wasted at the farm level due to poor planning and lack of responsibility on the part of small-holder famers that have entered into farming arrangements with the Government of Lesotho (GoL)21. Figure 8: Cereal production in 2017 comparing with ten, five year averages reference year and last year 15 All statistics in this paragraph is from Lesotho National AIDS Commission UNAIDS (2009): Modes of Transmission Study 9 16 MOH (2015): Gender Assessment in Lesotho – summary notes, UNAIDS 17 MOH (2014): Lesotho Demographic and health Survey pg. 35 18 http://www.ifpri.org/publication/2017-global-hunger-index-inequalities-hunger 19 Lesotho Vulnerability Assessment Committee, June 2017, Lesotho Annual Vulnerability Assessment and Analysis Report, 20 Cereal production in 2017 comparing with ten, five year averages reference year and last year (Source: Bureau of statistics) 21 FNCO, 2017 Lesotho Zero Hunger Strategic Review Draft Report Lesotho Food and Nutrition Strategy and Action Plan Page 23 Source: Bureau of Statistics Crop Production Statistics Report, 2017. 4.3.1 Food Accessibility and Affordability The majority of Basotho population relies on market purchases for food. Coupled with the heavy reliance on food imports, which makes Lesotho susceptible to high food prices, this increases pressure on vulnerable households’ food security. Low-income earners and the poor especially the rural population struggle to meet their minimum daily requirements for food intake as they can only access poor quality foods with low micronutrient content. It is important to note that national prices for maize have been relatively stable throughout 2017. Purchasing power also remained relatively stable across the first 4 months of 2017, with one day's worth of labour purchasing 8kgs of maize meal. The country mostly depends on purchases of cereal and is therefore vulnerable to any cereal price fluctuations in the neighbouring South Africa. Fewer households are adopting coping strategies in comparison with last year; however, dietary diversity and levels of food consumption are still inadequate. 4.3.2 Food Utilization Food consumption is at borderline and acceptable levels. Based on the recent LVAC, eight percent urban households had poor food consumption compared to 15 percent of rural households. Rural areas of Mokhotlong, Mohale’s Hoek and Berea had more households (22- 31%) with poor food consumption than rural areas in other districts. Mokhotlong and Berea urban also recorded the highest proportion of households with poor food consumption (15% and 17% respectively) compared to other urban. Consumption of Vitamin A rich foods is higher than consumption of iron rich foods in most households across the country in the case of urban and rural areas. The highly consumed vitamin A rich foods in the rural areas is green leafy vegetables and this was evidenced in the LVAC report which indicated that 30-60 percent of rural households consumed vitamin A rich foods on daily basis. Additionally, the LVAC 2017 report showed that iron rich foods were the least consumed foods, with 43-71% households recording no consumption of this food group at all, while 27-53% recorded consumption of protein rich foods ‘sometimes’ (1-6 days). According to the LVAC report 2017, consumption of iron rich foods remained low even in urban areas. However, urban households of Mafeteng presented a different picture as 96% consumed vitamin A rich foods daily, 87% consumed protein rich foods and 61% consumed iron rich foods (Figure 9). Figure 9: Food Consumption by Settlement and District Lesotho Food and Nutrition Strategy and Action Plan Page 24 Source: LVAC 2017 Report. 4.3.3 Dietary Diversification Dietary diversity remains a major challenge for most households in Lesotho including those that have acceptable food consumption score. The DHS 2014 report indicated that only 11 percent of children aged six to 59 months received minimum acceptable diet. This was also evidenced in the recent LVAC report that indicated that there was a slight improvement from the previous year, from 90 percent to 82 percent. Additionally, the report illustrated that dietary diversity was lower for children at rural areas (84.3 percent) compared to urban areas (78.4percent) but similar for boys compared to girls. Furthermore, based on the recent vulnerability assessment conducted in 2017, just about half of rural households with acceptable food consumption had low dietary diversity, 41 percent had moderate dietary diversity while only 8 percent had high diversity and only 20 percent of households in acceptable food consumption score group had high dietary diversity (Figure 10). This clearly indicates that most households rely on diets that lack diversity. Figure 10: Dietary Diversity by Settlement and District Source: LVAC 2017 Report. Lesotho Food and Nutrition Strategy and Action Plan Page 25 Food distribution has also been a challenge due to poor road networks and unorganized markets for farmers and other traders to display their food products, lack of food storage facilities which has led of food wastage due to improper storage; poor road networks and rural urban divide which has made food produced in rural areas not be able to be distributed to urban centres or food imported not be able to reach certain rural households. 4.4 SWOT Analysis An analysis of the strengths, weaknesses, opportunities and threats associated with previous and on-going initiatives informed the choice of strategies. The SWOT analysis is summarised in Table 3. Table 3: SWOT Analysis of Previous Initiatives to Achieve Food and Nutrition Security Strengths  Existence of FNCO with Staff in every district  FNCO is under the Prime Minister's office  FNCO committees established based on various thematic areas  Decentralized structures with qualified staff  Sector nutrition programmes up to the district and sometimes community level  Higher learning institutions offering nutrition courses  There is nutrition research unit  We have a high level political involvement in nutrition issues  Availability of Nutrition policy and global nutrition movements; SUN, Cost of Hunger Study, Zero Hunger Strategic Review Study and National Food and Nutrition Strategy (in process)  School feeding program has increased the school attendance, also free Primary education is a success Weaknesses  Inadequate partner collaboration and coordination  Inadequate multi-sectoral accountability and coordination  Weak sectoral structures leading to limited service delivery  Inadequate advocacy on nutrition  Inadequate funding for nutrition  Inadequate monitoring and evaluation systems  Inadequate activity from Lesotho Food and Nutrition Council (LFNC)  Lack of food quality control systems and standards  Lack of food and nutrition information system  Inadequate human resources  Inadequate data for informed decision making Opportunities  Drought and resulting food shortages coupled with rising food prices has brought nutrition to the forefront for Government  Climate change and building resilience have brought the focus of attention to nutrition  Increasing numbers of children and adults who are overweight and/or obese and attention to healthy lifestyles  Sector technical staff are cognisant of the need for multi-sector and multi-stakeholder involvement as well as the coordination role of FNCO  The hitherto involved sectors have delineated roles in fulfilling the national nutrition programme targets and fulfilling their sector mandates.  Nutrition on the spotlight as a result of His Majesty being an African Nutrition Champion and FAO Nutrition ambassador  Exploration of Climate Smart Agricultural Opportunities Threats  Inadequate appreciation of the roles of different sectors and the line of accountability vis a vis authority  Worsening malnutrition with the drought and poor or no harvests  Increasing poverty and lack of resources  Increasing incidences of diseases (co, thus low food production.  Government works towards curative than preventive  Increasing numbers of children and adults who are overweight and/or obese and attention to healthy lifestyles  The uncontrolled marketing of traditional and locally produced products (supplements, Remedies)  Political instability hinders implementation of nutrition activities Lesotho Food and Nutrition Strategy and Action Plan Page 26  Development partners, NGO and private sector willing to support nutrition programmes  Food and Nutrition strategy development, a review is being taken of the Zero hunger strategy  Lesotho taking part in the global nutrition movements – SUN – there should be the 5 functional committee  The availability of COHA study to use as reference material  Her Majesty’s breastfeeding advocate and early childhood development  There are cultural beliefs that negatively affect child feeding  Inconsistent messages on nutrition through media  No control of food products claiming to have high nutrition value environmental degradation  Poor nutrition governance structures  Lack of implementation of the code inadequate access to nutrition and health facilities 4.5 Political, Economic, Social, Technological, Environmental and Governance Situation 4.5.1 Political Analysis Lesotho is a Kingdom with His majesty The King as Head of State while that of Government is the Prime Minister. Lesotho is governed through a democratic governance with a Parliament comprised of the Senate and a National Assembly whose membership are both a first at the goalpost elected and party proportionate representation members. The Executive arm of Government is the Cabinet of Ministers. Since independence from Britain in 1966 the country has gone through several styles of government including autocracy rule, military rule, winning party rule and coalition governments. The instability in governments and uncertainty of coalitions has to a large extent distracted attention from long term socio-economic development to short term political gains. The unstable polity and the resultant unpredictability of policy has negatively affected investment on nutrition. His Majesty King Letsie III in 2014 has been nominated by African Union as the Champion on Nutrition and in 2016 by Food and Agricultural Organization (FAO) as an Ambassador of Food Security. Internationally and continentally he has made tremendous strides in advocating for nutrition. To make this role a national reality, in his Speech from the Throne, during the 10th Parliament, he expressed his commitment to put rigorous efforts towards addressing the challenges of malnutrition and food insecurity that currently face the nation. This high-level advocacy role of His Majesty should further facilitate and catalyse implementation of the cost- effective interventions in Lesotho. 4.5.2 Economic Analysis The country is classified as a Lower Middle Income country ranked number 161 of the 187 countries on the Human Development Index (0.49722). The economy of Lesotho is highly affected by its central location in Southern Africa. Lesotho is a member of the Southern African Customs Union, the Common Monetary Area and the Southern African Development Community (SADC). South Africa remains the largest trading partner and import as well as export market. Agriculture and Industry each contribute 8% and 31.2% of the Gross Domestic Product (GDP) (UN Data 2015), respectively. Thirty Six Percent (36%) of households are headed by females in both urban and rural areas. This is attributed to the migration of many women to urban areas due to the proliferation of the textile industry, which predominantly employ women, and to the fact that 22 UNDP 2015: Human Development Report – Sustaining Human Development Lesotho Food and Nutrition Strategy and Action Plan Page 27 a significant number of Basotho men live in South Africa as migrant workers23. Half of all married women and 85 per cent of married men aged between 15-49 years are employed. Of the employed women, 83% are paid cash and 13% do not receive any earnings for their work while among men 78% are paid cash while 15% do not receive any pay.24 The report on the Cost of Hunger Study in Africa (COHA) Lesotho 2016, shows that of the 33.2% of the children in Lesotho who are stunted, only 42% are estimated to be receiving proper health attention, and most of the health costs associated with undernutrition occur before the child turns one year old. 19.5% of all child mortality are associated with undernutrition, 17.7% of all repetitions in schools are associated with stunting, and stunted children achieve 3.6 years less in school. The child mortality associated with undernutrition has reduced Lesotho’s work force by 7.2%. The report further indicates that 45% of the adult population in Lesotho is estimated to have suffered from stunting as children. The annual costs associated with child under-nutrition are estimated at 1.9 Billion Maluti or 7.13% of the GDP. 25 Inequality is significant in Lesotho; the wealthiest quintile secures 60% of the national income while the lowest quintile only receives 2.8 per cent26. According to the LDHS 2014 85% of the wealthiest people live in the urban areas while 54% of the rural residents constitute the lowest wealth quintile. The wealthier households tend to reside in the lowland areas and half of the poorest households live in the mountains. Poverty prevalence is similar in rural and urban areas. The adult literacy rate is 87% (79.7% male and 93.6% females). The completion of school varies by topographic area and gender, higher for girls and for urban residence.27 The unemployment rate is estimated at 22.7% (UN Data = 26.4%) with a total dependency ratio of 67/100 population 15-64 years. The Life expectancy at Birth is 41 years28 (UN Data 2015= 49.6 years females and 49.2 years males). The orphan and vulnerable children population is estimated at 125,000 of whom 30,000 are most vulnerable and requiring urgent support;29 a high proportion of children under 18 years (27 %) are being orphaned.30 However, Lesotho has made progress in poverty reduction in the 2000s by lowering its headcount poverty rate ($1.9/day PPP) from 61.3% in the year 2002 to 59.7% in 2011, though estimates for 2016 suggest that 57.8% of the population is still trapped under extreme povertyi. These improvements can be attributed to the Government’s involvement on the concerted and coordinated efforts to redress most if not all of the nutrition challenges faced by the country such as joining the Scaling-Up Nutrition (SUN) global movement in 2014 and utilizing the United Nations family concept of “Delivering Together as One”31. UN partners such as the WFP, FAO, United Nations Children Fund (UNICEF), and WHO are committed to providing technical and financial assistance and guidance in identifying the most effective strategies for comprehensively addressing the triple -burden of malnutrition in Lesotho through multiple mechanisms. 4.5.3 Social Analysis The population of Lesotho is patriarchal and patrilineal. While women are the main caretakers for children, they have little access to economic resources outside their husbands and male family 23In the past the majority of the Basotho men used to work in the mining industries in South Africa. Nowadays it is a lower number but still about 20 per cent of the men. There is an increasing number of Basotho women who (seasonally) migrate to South Africa to work on agricultural farms and as domestics. 24 Ministry of Health 2014, Lesotho Demographic Health Survey 25 Government of Lesotho, African Union, NEPAD, UNDP, WFP, UNICEF, Cost of Hunger in Africa, Lesotho 26 Figures cited in the NSDP II (from the African Peer Review Mechanism, Country Report No. 12, June 2010). 27 Ministry of Health 2014, Lesotho Demographic Health Survey 28Ministry of Health and Social Welfare 2009, Lesotho Demographic and Health Survey 29 Ministry of Health 2015, Updated Situation Analysis (SitAN) for Adolescents and Young People in Lesotho 30 The 2006 Census found that there were 221,000 single or double orphans (28.5 per cent of all children 0-17 years). 31 UNDAF 2017 Lesotho Food and Nutrition Strategy and Action Plan Page 28 members. Furthermore, nutritionists are mostly women, and this continues to reinforce the cultural norms that food and nutrition are women’s issues and not national issues. In addition, land and other assets are usually the domain of men. The socio-cultural dynamics embedded in society are disempowering women from making decisions about the allocation of finances and other resources to access and meet dietary requirements. Several policies and laws have however been enacted in addressing the gender imbalances but implementation is still weak. There are wide variations in the levels of malnutrition by demographic variables such urban-rural abode and level of education of mothers. In 2014, the proportion of the population using improved water sources was estimated at 97% and 77% for the urban and rural populations respectively.32 Currently, the Government of Lesotho has embarked on strategies to combat food and nutrition insecurity for the vulnerable members of society. Furthermore, assistance by development partners instituted a number of social protection programmes. Spending on social protection grew remarkably over the years. In 2016, the country was spending 9.6 percent of GDP on Social transfer programmes, well above the 1-2 per cent allocated by most developing countries33. 4.5.4 Technological analysis Application of technology both in communication and energy as well as fuel saving is important for nutrition. Furthermore, Lesotho does not have any Food and Nutrition Information System. Hence implementers in nutrition utilize their sector specific information systems, though there is no coordinated and streamlined system which enables data collection, analysis, dissemination and utilization of information at local, district and national levels. However currently, there is multi-sectoral Nutrition Surveillance System coordinated by FNCO which needs to be strengthened. 4.5.5 Information Communication Technologies for Nutrition Lesotho’s access to Information Communication Technologies (ICT’s) is measured by the number of connections for both fixed and mobile services per every 100 inhabitants, normally referred to as tele-density. During the period 2014-15, overall sector tele-density for both fixed and mobile subscribers increased from 96% to 124% based on the 2006 population census figure of 1,880,661134. Regular radio education and mobilization programmes are held by various stakeholders including those in nutrition. The system is however not well streamlined for effective nutrition advocacy and community mobilization. This weakness is across the continuum of food production, distribution, consumption and populating nutrition. Cell-phone companies distribute messages as and when requested or as part of their social responsibility. This avenue is also not well explored nor utilized to promote public understanding of nutrition effectively. 4.5.6 Food Fortification Micronutrient malnutrition is common globally; particularly afflicting young children and pregnant women in developing countries. Efforts to counter micronutrients malnutrition seek ways of fortification if food with micronutrient has been adopted as a method of choice due to its ease of application to large sections of the population. This is particularly true with flour fortification since is mostly consumed. Presently, fortification in Lesotho remains voluntary as some producers have on their own initiated food fortification, and this needs to be standardized and effectively monitored. It is therefore important to institute arrangements that will make it mandatory.. 32 Ministry of Health 2014, Lesotho Demographic Health Survey 33 Government of the Kingdom of Lesotho, Ministry of Social Development (March 2014, First draft). National Social Protection Strategy 34 Lesotho Communications Authority Report (2016) Lesotho Food and Nutrition Strategy and Action Plan Page 29 4.5.7 Energy The improvement in nutrition observed in some countries has also been associated with the adoption of energy saving technologies for women as well as fuel saving given the paucity of sources of fuel especially in rural areas. Energy saving technologies in the context of reducing carbon foot prints and saving limited fuel are available in Lesotho. However the information dissemination and adoption of these technologies is still low. There is therefore the need to develop the standards and guidelines as well as quality assurance (based on area) and adoption, in order to address food and nutrition security throughout the value chain spectrum: from production, processing, preservation, storage, consumption and utilization. All these need to be considered in the context of available technological capabilities. 4.6 Environment and Climate Change The unprecedented El Niño phenomenon has affected Southern African harvests through two consecutive seasons of drought, extensive dry spells, and late and erratic rains. Lesotho’s food production has also been affected. Rough estimates placed maize (staple food) production in Lesotho for the 2015-16 harvest at 35,000 tonnes, down from 74,000 tonnes in 2014-15, a decrease of 47% from 2014-15ii. The LVAC Rapid Assessment conducted in January 2016 found the estimated total number of food insecure people in Lesotho to have increased to 534,502 people from 463,936 in July 2015, representing a 15.2 percent increase which is attributed largely to the worsening drought and resulting bad harvest in the region. This ordeal led to Lesotho, Malawi, Swaziland and Zimbabwe declaring a state of drought emergency (December 2015 – February 2016) while Mozambique issued a state of red alert related to the worsening drought. Lesotho’s reoccurring extreme weather events such as droughts, desertification, erratic rainfall and other natural disasters like snowfall, hailstorms, early frost and strong winds and limited amount of suitable arable land are expected to worsen the variability and intensify their impact on the economy and general livelihoods. This challenge of food and nutrition insecurity is also aggravated by the palpable extent of desertification and land degradation. The effects of soil erosion and land degradation have already reduced the productive capacity of Lesotho’s croplands and rangelands. And will continue to hamstring efforts to improve production efficiencies and total production in the face of climate change impacts estimated a total sediment soil yield of about 1400 million tons in reservoirs per annum. In 2009 the maximum soil loss predicted by the RUSLE model is over 50 million tons per hectare per year with most erosion recorded in the mountain areas and the southern lowlands districts (Makara, 2013). The most critical areas where erosion still active falls within north-eastern highland and parts of Mohokare catchment in the northern lowlands. 4.7 Nutrition Governance Situation35 The Kingdom of Lesotho has made a commitment to scale up nutrition in 2014 when Lesotho joined the Scaling-up Nutrition Movement. His Majesty King Letsie III is the African Union Champion for Nutrition and FAO Special Ambassador for Nutrition, and these roles have increased the coverage of and attention to nutrition issues in the country. The launch of the National Nutrition Policy in 2016 marked a significant milestone as it will provide guidance to sectors on the comprehensive approach to address malnutrition using evidence- based strategies to maximize impact. 35 The narrative in this section is based on, and extracted from, the findings of the Food and Nutrition Security Coordination Capacity Assessment Study commissioned by FNCO and REACH in 2017 and conducted by Dr Makholu Matete. Lesotho Food and Nutrition Strategy and Action Plan Page 30 Nutrition programmes are located across several ministries that have food and/or nutrition security mandates. The key ministries with nutrition departments of units are: Ministry of Health (MOH), Ministry of Agriculture and Food Security (MoAFS), Ministry of Education and Training (MOET). The FNCO which is located in the Cabinet Office is responsible for providing strategic leadership and coordination to the sector. The MoH Nutrition Unit, which is located in the Family Health Division, has a policy on Infant and Young Child Feeding, which informs their work. The MoH implements nutrition-specific programmes through the clinics and at community level through village health workers. The MoAFS Nutrition Division, in the Department of Field Services is responsible for implementing nutrition-sensitive actions implemented at community level. This happens with the support of Nutrition Subject Matter Specialists and Agriculture Assistants at community level. The work of the Nutrition Division is guided by the MoAFS Food Security Policy. MoET has an Early Childhood Care and Development (ECCD) Policy, which has informed activities in the care of children under five years through the ECCD network of schools at community level. With the support of REACH and UNICEF, FNCO has been able to undertake several studies in nutrition and governance which will guide and inform the work of multi-sectoral nutrition in order to achieve the scaling up activities in Lesotho. With the support of REACH and UN Network (FAO, UNICEF, WFP and WHO), FNCO has been able to undertake several studies in nutrition and governance which will inform the work of multi-sectoral nutrition in order to achieve the scaling-up of core nutrition activities in Lesotho. The main findings on the nutrition governance situation point to the existence of weak legal and policy frameworks in the country which do not adequately provide an enabling environment for multi-sectoral nutrition. They also emphasise the need for nutrition to be mainstreamed in all policies, frameworks and strategies and the importance of strengthening the nutrition coordination mechanisms. The Food and Nutrition Commission was established in 1998 through a Cabinet Memorandum and had a Cabinet Sub-committee chaired by the Prime Minister. This structure has not been functioning for a number of years due to inadequate expertise, lack of knowledge about nutrition and its impact on the population and economy, therefore rendering nutrition a low priority in Lesotho. In order for scaling-up nutrition efforts to be successful support and leadership at the highest levels of government is required. The structure of the FNCO lacks experienced senior managers with functional skills, and lacks technical capacity at national and district levels to guide and direct staff and all key stakeholders in the sector. Financial resources, equipment and infrastructure are severely lacking. The FNCO capacity must be strengthened in all these areas if it is expected to lead implementation of the Food and Nutrition Policy and Strategy. The collaboration mechanisms are also weak and cannot facilitate effective multi-sectoral collaboration. The nutrition units within key ministries are severely inadequate to inadequate nutritionist at national and district levels, the structures are also weak due to their low locations in the ministries and lack decision making power and other resources to effectively implement sectoral nutrition policies and strategies. Lesotho Food and Nutrition Strategy and Action Plan Page 31 5 KEY RESULT AREAS 5.1 Process of Identifying, and Criteria for Prioritising the Key Result Areas (KRAs) The process of identifying KRAs started with the Multi-sectoral Nutrition Overview (MNO) which was a desk review of the nutrition situation covering the following domains: maternal and child health, micronutrient supplementation, infant and young child feeding, food security and livelihoods, water sanitation and hygiene and poverty. The second step was to consider the indicator trends and the status comparing them with the global thresholds. Interventions were then drawn from the SUN Compendium of Nutrition Actions (evidence based interventions), then grouped them into clusters (or KRAs) guided by the Conceptual Framework for Nutrition. The resultant KRAs for the FNSAP were more detailed and involved some reclassification of the original domains of the MNO. 5.2 Weighting of the Key Result Areas Table 4 shows the key result areas and government institutions and partners responsible for the implementation of strategies prioritised under each KRA. The weighting is based on the gap that needs to be resolved. It is based on the types of core nutrition actions that are needed, the relative magnitude of investment to be made to reverse or improve trends observed in terms of the nutrition situation observed from recent data. The weights also take into consideration their relevance as indicated by the main objectives in the Lesotho Food and Nutrition Policy. Table 4: Weighted key result areas, responsible government institutions and partners No. KRA Weight (%) Government Institutions Responsible Other Partners 1 IYCF 13% Ministry of Health, Ministry of Agriculture and Food Security UNICEF, WHO, WFP, EGPAF, Baylor, 2 Micronutrient supplementation 9% Ministry of Health, Ministry of Trade, Ministry of Education and Training, Ministry of Agriculture and Food Security UNICEF, WHO, WFP 3 Maternal and Child Health 8% Ministry of Health, Ministry of Agriculture and Food Security UNICEF, WHO, WFP, UNAIDS, EGPAF 4 Food Value Chain 20% Ministry of Agriculture and Food Security, Ministry of Health, Ministry of Trade, Ministry of Local Government. Ministry of Forestry and Land Reclamation. FAO, WB, Lesotho Flour Mills, Lesotho Milling company, 5 WASH 5% Ministry of Water, Ministry of Health, Ministry of Environment, Ministry of Education and Training TED, WHO, WASCO, UNICEF, World Vision, ADRA, Red Cross 6 Social Protection 5% Ministry of social Development, Ministry of Finance, Ministry of Education and Training, Ministry of Small Business. UNICEF, WFP, FAO, World Vision, CRS, 7 Capacity building 14% Ministry of Education and UNICEF, WHO, WFP, Lesotho Food and Nutrition Strategy and Action Plan Page 32 Training, Prime Minister’s Office, Ministry of Development Planning FAO 8 Enabling environment 13% Prime minister’s Office, Ministry of Finance, Ministry of Development Planning. UNDP, UNAIDS, WHO 9 Gender 5% Ministry of Health, Ministry of Gender youth sports and recreation, Ministry of Communication science and Technology. FAO, WFP, WHO, GLOBAL FUND, 10 Strengthening Clinical Services 4% Ministry of Health, Ministry of Agriculture and Food Security, WHO, UNICEF, EGPAF, GLOBAL FUND, 11 Nutrition in Emergencies 4% Prime minister’s Office, Ministry of Health, Ministry of Finance, Ministry of Policy, Ministry of Defence WHO, WFP, UNICEF, EGPAF, GLOBAL FUND, Total 100% Lesotho Food and Nutrition Strategy and Action Plan Page 33 6 CLIENT’S NEEDS AND PROBLEM ANALYSIS The Lesotho Food and Nutrition Strategy and Action Plan is informed by a thorough desk review analysis of the needs of the clients and understanding the characteristics of the problems they are facing. These clients are classified according to a lifecycle approach described in Table 5 below specifically focusing on the problems, the needs, the extent and causes. Table 5: Client problems, needs, characteristics and extent Item Client Needs/ Problem Characteristics/Extent 1 Women of Child Bearing Age (15-49) Needs  nutrition assessment, screening  prevention of HIV and STI infections and unplanned pregnancies  health and nutrition education, and counselling  provision of nutrient-dense food  micronutrient supplementation particularly iron  counselling and support for adherence to ART treatment  less labour-intensive/energy saving devices  protective environment that support IYCF(Maternity protection) Extent:  41.8% of women have a problem accessing health care services (LDHS 2014)  46.5% of women in child bearing age are anaemic (LDHS 2014)  15% of women aged 15 to 19 years have given birth 29.7% of women 15-49 years are HIV+ (LDHS 2014)  31.9% of women are overweight and obese (LDHS 2014)  77.3% of women are not receiving postnatal care (LDHS 2014) Problem:  accessing health care  iron Deficiency Anaemia  teenage pregnancy  lack of ANC education especially within the first 4 months of pregnancy  do not receive postnatal care in time  High HIV prevalence  over nutrition (Obesity/overweight)  cancer (breast and cervical)  non communicable diseases Causes:  lack of access to health care  Insufficient consumption of iron- rich foods  high soil helminths  Presence of iron inhibitors in the diet and insufficient spacing between consumption of these foods and iron sources  multiple concurrent partners  inadequate knowledge  poor eating habits 2 Children 0-5 months Needs:  exclusive breastfeeding Extent:  33.1% are not exclusively Lesotho Food and Nutrition Strategy and Action Plan Page 34 Item Client Needs/ Problem Characteristics/Extent  adherence to ART treatment during breastfeeding by the mother  clean healthy environment  care and stimulation in all its forms  immunization  protective environment that support IYCF  Management of early childhood illnesses breastfed (LDHS 2014) Problem:  mixed feeding  malnutrition  recurrent illness  micronutrient deficiencies  at risk of mother to child transmission (MTCT) of HIV Causes:  inadequate knowledge on exclusive breastfeeding, cultural practices, poor sanitation and hygiene practices  inadequate access to health care services 3 Children 6-59 months Needs:  receive optimal quality IYCF  attendance to receive MCH services that include growth monitoring, education counselling and vaccination, management of malnutrition, early childhood care and development  deworming tablets supply Extent:  51.8% of children 6-59 months have anaemia (LDHS 2014)  32.7% of children 6-59 months Vit A Coverage (LDHS 2014)  33.2% stunting in under-fives (LDHS 2014)  90.2/1000LB under five mortality rate (LDHS 2014)  11.3% of children 6-23 months receive minimum acceptable diet according to the Infant and Young Child Feeding (IYCF) practices (LDHS 2014)  68.3% of children aged 12-23 months received all recommended vaccinations nationally (LDHS 2014)  7% of under-fives are overweight (LDHS 2014) Problem:  children 6-23 months are not fed according to appropriate (IYCF) practices  iron deficiency  vaccination coverage low  high stunting rate  high mortality-  overweight  Worm manifestation in children Causes:  negligence  poor sanitation and hygiene practices  poor diet, poverty and food insecurity  poor access to health services,  recurrent childhood illnesses 4 5-14years Need:  adolescent friendly Extent:  25% of teen females married Lesotho Food and Nutrition Strategy and Action Plan Page 35 Item Client Needs/ Problem Characteristics/Extent services,  School health  NACS before the age of 18years (LDHS 2014)  78.3% of teen males engaged in economic activities (LDHS 2014) Problem:  HIV infections  Poor diet and eating habits  under and over nutrition  Alcohol, drug and other substances abuse  early childhood marriages  Child labour Causes:  cultural practice  inadequate knowledge  unprotected sex  multiple concurrent partners  peer pressure  poverty 5 Females 15- 49years Need:  diet diversification,  sexual Reproductive Health (SRH) services,  reliable job opportunities Extent:  18.8% of females are hypertensive30% of females are HIV+ (LDHS 2014)  45% of women are overweight or obese (LDHS 2014) Problem:  teenage pregnancy  high school dropouts  Unemployment  HIV infection  poor health seeking behaviour  Cervical and breast cancer  Lack of SRH education  alcohol and drug abuse  poor eating habits Causes:  inadequate knowledge of food and nutrition and SRH   peer pressure  Poverty, and food insecurity  judgemental attitudes by health care providers  children living alone, without the guidance of parents  Poor food choices 6 males 15-49 years Need:  men friendly services  nutrition assessment counselling and support (NACS) Extent:  18.6% of males are HIV+  13% of males are hypertensive (LDHS 2014)  14% of males are anaemic (LDHS 2014)  13.5% of males are using cigarettes/tobacco (LDHS 2014)  12% of males are overweight or obese and 7% are obese (LDHS 2014) Problem:  HIV infection  poor health seeking behaviour  poor dietary intake  anaemia  Alcohol, drug and other substance abuse  hypertension  prostate cancer  obesity/ overweight Cause:  cultural believes and norms  multiple concurrent partners  unprotected sex  poor eating habits 7 Above 49 years Need:  diet diversification Extent:  No data for this age group Lesotho Food and Nutrition Strategy and Action Plan Page 36 Item Client Needs/ Problem Characteristics/Extent  health care and support  nutrition assessment counselling and support (NACS)  food supplementation Problem:  micronutrients deficiency (anaemia)  poor dentals  exposed to HIV infection  osteoporosis  non-communicable diseases Cause:  poor dietary intake  lack of information  cultural beliefs and norms  poverty 8 Households Needs:  access to land  food security  sustainable water sources  improved sanitation facilities  stable income Extent:  28% of rural household have no access to improved water sources (LDHS 2014)  63.6% households food insecure (LDHS 2014)  27.42% unemployment rate (BOS)  28% earn their main income from farming  50% of the population faces food deficit (LVAC, 2016) Problem:  food insecurity  insufficient accessibility to improved water source  poor sanitation and hygiene  poor eating habits Causes:  climate change vs poor agricultural practices  high food prices  poverty  high employment rate 7 STAKEHOLDER ANALYSIS This section outlines the stakeholders based on their functional roles as advisory, policy oversight, coordination, implementation, monitoring and evaluation. The government sectors are identified based on their mandate. The Prime Minister’s Office provides oversight, the Food and Nutrition Coordinating Office coordinates and the line ministries implement. The other stakeholders are identified based on the activities they support or implement and these include the Development Partners, Civil Society Organisations, Donors (international and local), UN agencies and the private sector (Table 6). Table 6: Stakeholder demands and expectations and their characteristics Stakeholder Demands and expectations Characteristics and extent Prime Minister’s office  Information and orientation on nutrition and their role  Advocacy toolkits 10% Lesotho Food and Nutrition Strategy and Action Plan Page 37 Stakeholder Demands and expectations Characteristics and extent Food and nutrition coordinating office  Elevation to a commission level  Skilled human resources  Logistic capacity  Funding  Systems/networks for coordinated nutrition  Corporation from stakeholders 15% Government line ministries and agencies  Guidelines and standards  Institutional capacity building 20% Civil society  Clear policies and strategies  Guidelines and standards  Collaboration and coordination 5% UN agencies  Clear policies and strategies  Priorities  Government commitment and resource allocation for nutrition  Collaboration and coordination 5% Donors  Clear policies and strategies  Priorities  Government commitment and resource allocation for nutrition  Collaboration and coordination 5% Private sector  Clear policies and standards  Tax rebates  Visible results 5% Staff from the line ministries and sectors  Motivation  Supervision  capacity  Guidelines  Coordination 10% Communities  Acknowledgement, Involvement and participation  Empowerment through training  Decentralized, effective and friendly services  Accessible services  Respect for their of rights 20% Individuals  Effective, accessible, user friendly and technologically appropriate services  Respect for their rights  Empowerment through nutrition education and counselling 5% Note: The percentages reflect the relative importance of this demand in shaping the priorities in this strategy and action plan. 8 POLICY REQUIREMENTS The design of the Lesotho Food and Nutrition Strategy and Action Plan (LFNSAP) and its implementation takes cognisance of the existence of other guiding policy and strategy documents in the country. The Food and Nutrition Security Policy adopted in 2016 provides the overall framework for development of the LFNSAP. The performance targets are in harmony with global as well as regional, continental and national commitments and development aspirations. The targets are consistent with the Sustainable Development Goals, the National Development Plan targets and Health Sector Strategy aspirations. The LFNSAP recognizes that achieving food and nutrition security will take the shared commitment and contribution of all stakeholders including the donor community, NGOs, the private sector, the research and training institutions, Lesotho Food and Nutrition Strategy and Action Plan Page 38 and government entities responsible for implementation of the various components of the strategies enunciated in this document. The implementation of the strategies contained here shall be guided not only by the Food and Nutrition Security Policy but also other policies, strategies and guidelines that will be implemented during the same time as the FNSAP (see Table 7 below for the list of policies, strategies and other national documents linked to the FNSAP). Table 7: Existing Sectors’ Acts, Policies, Strategies and Guidelines Sectors Relevant Acts, Policies, Strategic Plans and Guidelines Ministry of Agriculture and Food Security - Seed Policy (2015) - National Action Plan for food security (2006) - Lesotho food Security Policy and Strategic guidelines (2005) - Draft Plant Protection Policy - Draft irrigation policy - Draft plant protection policy - Subsidy policy - Agricultural sector strategy Ministry of Water - National Water and Sanitation Policy (2007) - Water Act no 15 of 2008 Ministry of Education and Training - National Policy For integrated Early Childhood Care and Development (2013) - National School Feeding Policy (2015) - School Health and Nutrition (2016) Draft - Lesotho Curriculum and Assessment Policy 2009 Ministry of Health - National Guidelines on Infant and Young Child Feeding (2013) - MOH Nutrition Strategy 2012/13-2018/19 (2013) - Lesotho National Guidelines for Integrated Management of Acute Malnutrition (2016) - Lesotho Nutrition and Poverty Programme (2002) - Expanded program on immunisation (EPI) Policy 2010 - Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition Strategy (RMNCAH & N) 2017- 2027 (in draft) - Draft Code of Marketing of Breastmilk Substitutes - Health Sector Policy - Health Sector Strategic Plan - HIV and AIDS Strategic Plan - Salt Iodisation Regulation of 1999 - Village Health Work Training Guidelines and References book - Village Health Worker Register - Non-communicable Diseases Strategy - IYCF Guidelines and Manual National AIDS Commission - National HIV and AIDS Strategic Plan 2011/12 – 2015/16 Ministry of Social Development - Lesotho National Social Protection Strategy (2014) - National Policy on Orphans and Vulnerable Children (2005) - Child Act 1993 - National Strategic plan on Vulnerable Children 2012- 2017 Ministry of Small Business Development, Co-operatives - Agricultural Marketing Act 26 of 1967 - Lesotho Micro small and medium enterprise policy 2016 Ministry of Forestry and Land reclamation - National Forestry Policy (2008) - Forestry Act (1998) - Ministry of Forestry and Land Reclamation Strategic Plan 2014/2015- 2016/2017 Lesotho Food and Nutrition Strategy and Action Plan Page 39 Sectors Relevant Acts, Policies, Strategic Plans and Guidelines Ministry of Communication, Science and Technology - Lesotho Science and Technology Policy 2006-2011 Prime Minister’s Office (Cabinet) - Lesotho Food and Nutrition Policy 2016/2017 - Kingdom of Lesotho: Poverty Reduction Strategy (2004/2005- 2006/2007) - Zero Hunger Strategic Plan - Capacity Assessment Report - Disaster Risk Reduction Policy 2011 - Disaster Management Act 1997 - Disaster Management Manual 1997 - Disaster Management Plan 1996 - Lesotho National Plan of Action for Nutrition 1997 Gender - Lesotho Gender and Development Policy (2009) - Action Lesotho Gender Equality Policy (2014) 9 CHAPTER 9: GOALS OF THE STRATEGY Based on the situational analysis relating to food and nutrition a number of goals are proposed to guide future investments in this sector in the next five years. They are presented together with their weights and institutions responsible for delivering activities under these goals with FNCO carrying the mandate of oversight and coordination (Table 8). Table 8: Goals, weights, responsible organisations and KRA reference No. Goal Weight Responsible organisation KRA Ref 1. To increase the proportion of children 0-6 months exclusively breastfed from 67% to 80% by 2023 3% Ministry of Health (nut), MAFS(nut), Lesotho Breast Feeding Promotion Network (LBPN), EGPAF, World vision 1 2 To increase the proportion of children 6-23 months that are receiving continuing breastfeeding and adequate complementary feeding from 11.3% to 20% by 2023 6% Ministry of Agriculture and Food Security (nut, research) Ministry of Health (nut) 1 3 To increase the proportion of new born children that receive early initiation of breastfeeding (within the first hour of birth) from 65% to 80% 4% Ministry of Agriculture and Food Security (nut) Ministry of Health (nursing and nut) EGPAF 1 4 To reduce anaemia prevalence in children (6- 59 months) from 50.8% to 20% 3% Ministry of Agriculture and Food Security (nut, research) Ministry of Health (family health, nut) Ministry of Trade and Industry (standards) WHO, UNICEF 2 5 To increase Vitamin A coverage for children 6-59 months from 61.3% to 90% by 2023 2% Ministry of Health (family health, nut) Ministry of Education and Training Ministry of Agriculture and Food Security (nut) FAO, WHO, UNICEF 2 6 To increase the proportion of children 6- 23 months consuming foods rich in vitamin A from 60.5% to 85% by 2023 2% Ministry of Health (family health, nut) Ministry of Agriculture and Food Security (nut) FAO, WHO, UNICEF 7 To increase the proportion of households with iodised salt from 92.9% to 100% in 2023 2% Ministry of Health (environmental health) Ministry of Agriculture and Food Security (nut, research) Ministry of Police 2 Lesotho Food and Nutrition Strategy and Action Plan Page 40 No. Goal Weight Responsible organisation KRA Ref UNICEF Lesotho Salt Parkers Ministry of Trade Ministry of Education 8 To increase the proportion of women who receive post-natal care within 2 days after delivery from 62% to at least 80% by 2023 2% Ministry of Health (family health, nut and village health workers) Lesotho Planned Parenthood Association WHO 3 9 To increase vaccination coverage to two- thirds (from one third) and deworming coverage to from 31 to 90% for children under-five years by 2023 1% Ministry of Health (family health, nut), WHO, UNICEF 3 10 To increase the coverage of growth monitoring and promotion for under-fives at community level to 95% by 2023 2% Ministry of Health (family health, nut) Ministry of Agriculture and Food Security (nut) WHO, UNICEF 3 11 To increase the proportion of expectant mothers with first ANC visit within the first trimester from 41% to 60% by 2023. 2% Ministry of Health (family health, nut) Ministry of Agriculture and Food Security (nut) 3 12 To develop adolescent nutrition service guidelines and ensure at least 30% coverage of adolescent nutrition services by 2023 1% Ministry of Health Ministry of Agriculture Ministry of Education 3 13 To reduce the proportion of the population that is food insecure by 50% (from 25% to 12.5%) by 2023 5% Ministry of Agriculture and Food Security (research, horticulture and nut), Ministry of Communication, Science and Technology (ATS) 4 14 To increase the proportion of the population (with special focus on children 6-23 months, adolescent girls, women of child bearing age) consuming foods rich in iron, zinc and Vitamin A by 30% by 2023 5% Ministry of Agriculture and Food Security (research and nut), Ministry of Health (nut) 4 15 To reduce the population living under the national poverty line from 57.1% to 45% by 2023 5% Ministry of Small Business (marketing), Ministry of Agriculture and Food Security (research, nut, horticulture, crops and livestock) Ministry of finance Ministry of Forestry 4 16 To ensure all food is safe for human and animal consumption 5% Ministry of Agriculture and Food Security (research and nut) Ministry of Health (Environmental Health) Ministry of Trade and Industry (standards) Ministry of Small Businesses, Cooperatives and Marketing 4 17 To increase the proportion of the population provided with access to an improved source of drinking water to 90% in rural and 100% in urban areas, and ensure all households without access treat the water by 2023 1% Ministry of Health (Environmental Health) Ministry of Water (rural water supply, WASCO) 5 18 To increase the proportion of the population with access to an improved sanitation facility from 47.1% to 60% and those using a sanitation facility from 73% to 85% by 2023 2% Ministry of Health (environmental health) Ministry of Water ( rural water supply, WASCO) TED World Vision Ministry of Education 5 19 To increase the proportion of households with the ideal hand washing practices (water and soap) from 46% to 70% by 2023 2% Ministry of Health (environmental health) Ministry of Agriculture and Food Security (nut) Ministry of Education and Training 5 20 To increase the proportion of pregnant and nursing mothers and children who have access to health and nutrition services to 80% by 2023 1% Ministry of Agriculture and Food Security (nut) Ministry of Health (nut) Ministry of Social Development 6 Lesotho Food and Nutrition Strategy and Action Plan Page 41 No. Goal Weight Responsible organisation KRA Ref Ministry of Local Government and Chieftainship 21 To ensure that nutrition education, livelihoods strengthening, and graduation referral pathways to reduce dependency36 are integrated into all social safety nets37 by 2023 2% Ministry of Agriculture and Food Security (nut) Ministry of Social Development Disaster Management Authority 6 22 To ensure that nutritional needs of special vulnerable groups (such as the elderly, people living with HIV and AIDS and other chronic illnesses) are fully integrated into social protection programmes and interventions by 2023 1% Ministry of Agriculture and Food Security (nut) Ministry of Health (nut) Ministry of Social Development Ministry of Education and Training 6 23 To ensure that coverage of social protection programmes is expanded and duplication of efforts and double-dipping are reduced to below 5% by 2023 1% Ministry of Social Development Ministry of Development Planning (BOS) Ministry of Home Affairs 6 24 To fully establish38, strengthen39 and empower the multi-sectoral food and nutrition coordinating institutional framework at national, district and community levels by 2023 14% Prime Minister’s Office Ministry of Public Service (HR) Ministry of Development Planning Ministry of Education and Training Ministry of Finance 7 25 To increase resource allocation to nutrition to 3% of national budget and mobilise funding from development partners by 2023, to meet the scaling-up of nutrition commitment made by the country in 201440 6% Ministry of Finance Development Partners: WHO, UNICEF, WFP, FAO, UNAIDS 8 26 To develop new, review existing, and fully enforce food and nutrition legal frameworks (such as food fortification law, code of marketing of breastmilk substitutes, monitoring of salt iodisation, maternity protection, establishment of FNCO commission/authority, food safety law), guidelines and standards by 2020 4% Ministry of Law Ministry of Trade and Industry Ministry of Police Ministry of Health ( environmental health) Parliament Cabinet 8 27 To fully integrate nutrition into existing and new national and sectoral policies, strategies, plans and curricula by 2023 3% Ministry of Education and Training (NCDC) Ministry of Planning 8 28 To increase the proportion of mothers and care givers of children 0-23 months whose spouses are involved in optimal child feeding, hygiene and health care to 80% by 2023 2% Ministry of Health (nursing) 9 29 To increase the coverage of women of child- bearing age and caregivers of under-fives with access to appropriate labour-saving technologies for food production, processing, preservation and preparation, as well as water supply and purification to 40%41 by 2023 2% Ministry of Agriculture and Food Security (nut) Ministry of Water (WASCO and rural water supply) Ministry of Communication, Science and Technology (ATS) Ministry of Health (environmental health) 9 36 To ensure that at least 25% of the recipients of social assistance grants graduate out of the programmes by 2022. Ministry of Social Development runs a vocational programme for people living with disabilities to train them on agriculture, carpentry, sewing and knitting, and other skills. 37 OVC Bursary Programme addresses dependency syndrome by empowering children to gain education and work and take care of their families. 38 Including recruitment of nutrition officers at community level. Also includes an activity “capacity assessments in nutrition, health and education”. Ensuring that FNCO has a critical mass of staff and skills effectively driving its mandate. 39 Development of operational systems, management, finance, HR, Accounting systems for new structures. 40 Advocacy, resource mobilisation, sensitisation 41 To be revised when we unpack the goal and strategies Lesotho Food and Nutrition Strategy and Action Plan Page 42 No. Goal Weight Responsible organisation KRA Ref 30 To increase the proportion of women who participate in decisions42 on own health care, major household purchases and visit to family or relatives from 65% to 80% by 2023 1% Ministry of Gender 9 31 To reduce the prevalence of common risk factors of NCDs by 5% in 2023 and support coordinated response and integrated essential services for addressing NCDs. 1% Ministry of Health Ministry of Agriculture and Food Security (nut) 10 32 To ensure increase in proportion of health facilities (primary, secondary, tertiary institutions) providing quality nutrition services for (HIV&AIDS, TB, soil helminths) and non-communicable diseases increased to 75% by 2023 2% Ministry of Health 10 33 To increase the proportion of adult population practicing at least two or a combination of the top 5 healthy lifestyles to 50% by 2023 1% Ministry of Health Ministry of Agriculture and Food Security (nut) 10 34 To ensure timely access to adequately nutritious food for people affected by emergencies. 2% Prime Minister’s Office (FNCO, DMA) 11 35 Prevent deterioration of nutritional status and save lives of vulnerable groups/prevent mortality 2% Prime Minister’s Office (FNCO, DMA) Ministry of Social Development Ministry of Health 11 TOTAL 100% 10 STRATEGIES, ASSUMPTIONS AND RISKS 10.1. Infant and Young Child Feeding Infant and young child feeding has been proven is key to child survival and promotion of healthy growth and development thus reducing undernutrition which is estimated to be associated with 45% of all child deaths (i.e., 2.7 million child deaths annually) globally. The first 2 years of a child’s life are particularly important, as optimal nutrition during this period lowers morbidity and mortality, reduces the risk of chronic disease, and fosters better development overall. Optimal breastfeeding is so critical that it could save the lives of over 820 000 children under the age of 5 years each year ((UNICEF, 2017). The 2003 Lancet Child Survival Series ranked the top 15 preventative child survival interventions for their effectiveness in preventing under-five mortality. Exclusive breastfeeding up to six months of age and breastfeeding up to 24 months together with complementary feeding starting at six months were ranked high and estimated to prevent almost one-fifth of under-five mortality in developing countries (Jones G. et 42DHS indicator which is proposed as a proxy for decision-making power on resources for optimal child feeding, hygiene and health care Lesotho Food and Nutrition Strategy and Action Plan Page 43 al., 2003). The 2008 Lancet Nutrition Series also reinforced the significance of optimal IYCF on child survival43. In addition, evidence for the specific survival benefits of continued breastfeeding up to 24 months has shown protection against illness such as diarrhoea and respiratory infections. This “window of opportunity” to prevent undernutrition is the same period when the recommended infant and young child feeding practices are applied: exclusive breastfeeding for the first 6 months, continued breastfeeding to 24 months or beyond together with adequate, safe, and appropriate complementary feeding. Optimal IYCF not only protects a child from both under- and over-nutrition but also from their consequences later in life. An analysis of several studies has shown that breastfeeding may have a protective effect on the prevalence of obesity and is a cost-effective obesity intervention [64], [65]. In addition to protecting against obesity, breastfed infants have a lowered risk of several chronic conditions later in life compared to artificially-fed infants, including asthma, diabetes [66], heart disease [67], [68] and cardiac risk factors such as hypertension [69] and high cholesterol levels [70], as well as cancers such as childhood leukaemia [71] and breast cancer later in lifeiii WHO and UNICEF recommend early initiation of breastfeeding within 1 hour of birth; exclusive breastfeeding for the first 6 months of life; and introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to 2 years of age or beyond. However in Lesotho one in three children (33.1%) under 6 months is not exclusively breastfed, while only 11.3% are fed according to the appropriate IYCF practices (LDHS, 2014). Lesotho follows the internationally acknowledged IYCF strategic planning and implementation model as illustrated in Figure 11). Lesotho has prioritised four key areas for investment in IYCF:  Promote early initiation of early initiation of breastfeeding  Promote exclusive breastfeeding from 0 to 6 months.  Promote optimal continued breastfeeding and complementary feeding practices up to 24 months.  Promote optimal feeding practices for orphaned children. 43 The Lancet Maternal and Child Undernutrition Series 2008 Figure 11: Core actions for IYCF Lesotho Food and Nutrition Strategy and Action Plan Page 44 The Ministry of Health shall lead on all IYCF legislation, strategy, norms and standards, and annual work planning, while the FNCO will provide support on policy development and coordination mechanism for linking with other sectors. A standard minimum package of services will be developed by the Ministry of Health in consultation with all relevant actors, and IYCF key interventions will be properly reflected in the minimum package of services for health facilities and community health care. Pre-service curricula and in-service training will be provided to all relevant health workers and community workers through the local training institutions for health workers. Job descriptions and tasks of health workers will reflect IYCF, while work structures will be modified to include IYCF, mentoring and supportive supervision. IYCF services shall be fully institutionalized in all maternities, MCH clinics and community health care. Supervision of health staff will include IYCF and shall be conducted regularly. Management of supplies such as food supplements, health worker and community worker (HW/CW) job aids and communication materials shall be planned and well-coordinated with all relevant stakeholders. Budget-lines in support of IYCF will be provided for in line ministry allocations at national level and district budgets. IYCF key indicators and process benchmarks shall be fully integrated in HMIS and linked to standard operating procedures and quality assurance mechanisms. The key strategies, assumptions and risks associated with IYCF are summarised in the Table 9. Table 9: Key strategies, assumptions and risks associated with IYCF Goal Strategies Assumptions Risks Goal 1: To increase the proportion of children 0-6 months exclusively breastfed from 67% to 80% by 2023 1. Revive, establish and train breastfeeding support groups covering all the health facilities and the community in general 2. Reinforce implementation of the hospital breastfeeding policy and guidelines 1. There will be cooperation among the Nutrition Team members 2. Operating environment remains conducive for holding of public gatherings and campaigns 1. Poor attendance 2. The environment is not conducive for holding public gathering Goal 2: To increase the proportion of children 6-23 months that are receiving continued breastfeeding and adequate complementary feeding from 11.3% to 20% by 2023 1. Improve knowledge and skills in the preparation of weaning foods 2. Scale-up homestead gardens 1. There will be minimal adverse climatic effects 1. Resistance to change Goal 3: To increase the proportion of new born children that receive early initiation of 1. Improve knowledge and attitudes of pregnant women on the importance of delivery at health facilities 2. Create baby-friendly environment in health 1. Men are willing to participate in child care 2. community members and family members are supportive of the increased role of men in child care 1. Taboos and practices that negatively impact early initiation of B/F, EBF and male participation Lesotho Food and Nutrition Strategy and Action Plan Page 45 Goal Strategies Assumptions Risks breastfeeding (within the first hour of birth) from 65% to 80% facilities 3. Promote equal participation of men and women in breastfeeding 3. The health workers in facilities are willing to adopt baby-friendly concept even if it introduces additional workload 4. There will be high attendance of women at ANC 10.2. Micronutrient supplementation and fortification Approximately 300 million children globally had anaemia in 2011(WHA, 2012; WHO, 2012, WHO, 2015). Of all the groups affected by micronutrient deficiency (hidden hunger), it is women and children from low and middle income groups within developing countries who shoulder the greatest burden. It is estimated that severe anaemia kills more than 50,000 women a year during childbirth (WHA, 2012), iron deficiency alone undermines the health and energy of 40% of women in the developing world, 2 million children may die unnecessarily each year because they lack Vitamin A, zinc or other nutrients, 18 million babies are born mentally impaired due to iodine deficiency each year (GAIN, 2015). Of global concern are deficiencies in iron, vitamin A, zinc, folate, and iodine. In Lesotho, the prevalence of anaemia in children is 50.8%, 27% in women and 14% in men (LDHS, 2014) Micronutrient deficiencies are often referred to as ‘hidden hunger’ because they develop gradually over time, their devastating impact not seen until irreversible damage has been done. While a child may go to sleep each night with a full belly, micronutrient deficiencies mean that his or her body is still hungry for good nutrition. Consuming a diverse range of nutrient-dense foods alongside breastfeeding is the ideal way for young children to get essential micronutrients in their diets. But in many parts of the world, children’s diets contain insufficient micronutrients and deficiencies are widespread (UNICEF, 2017). Available evidence of two systematic reviews (WHO-CDC, 2011), following the Cochrane handbook for systematic reviews (Handbook, 2000), of interventions were conducted to assess the effects and safety of point-of-use fortification of foods with multiple micronutrient powders. Infants and young children from 6 to 23 months of age (Hanbook, 1999) who consumed foods fortified at the point-of-use with multiple micronutrients powders had a lower risk for the critical outcome of anaemia, with a 26% reduction compared to placebo or no intervention In Lesotho salt is iodized with additive potassium iodate. The 2014 LDHS tested for the presence of potassium iodate in household salt, overall salt was tested in 70% of households and salt was not tested in 24% of households due to lack of test kits in the first week of the survey. Among households in which salt was tested 93% had iodised salt. It should be noted that household salt was tested for the presence or absence of iodine; the iodine content in the salt was not measured. Three fifths of children 6-23 months (60.5%) consume foods rich in vitamin A, however the closer to 23 months a child is the more likely to consume vitamin A rich foods. About two thirds of children receive vitamin A supplementation (61.3%), however there are some disparities between districts. Furthermore there is no legal framework on food fortification, yet some industries are fortifying staple foods voluntarily according to WHO and South African Bureau of Standards, while some local millers are not fortifying their products, hence why there is a need for the development and enforcement of food fortification legislation. The use of multiple micronutrient powders is a preventive strategy for implementation at population level without screening for any condition or disease. Children diagnosed with anaemia should be treated appropriately, according to WHO and national guidelines. Anaemia is Lesotho Food and Nutrition Strategy and Action Plan Page 46 frequently caused by iron deficiency, but other factors may contribute to anaemia, including other micronutrient deficiencies (e.g. folic acid, zinc, vitamins A and B12), soil-transmitted helminths, other infections, and blood disorders (e.g. thalassaemias, sickle cell). Summary of actions The key actions prioritized by stakeholders consulted at national and district levels include:  Promoting home fortification of complementary foods (MNP);  Adapting food fortification standards and ensure compliance;  Promoting industrial fortification;  Promoting bio-fortification;  Promoting consumption of iodised salt (regulation, inspection, monitoring and enforcement of compliance and testing;  Promoting Vitamin A supplementation; and  Promoting Micronutrient supplementation during antenatal care (Iron and Folic acid). Strategies addressing micronutrient deficiencies The most conventional and widely practiced strategies used to address micronutrient malnutrition are supplementation and food fortification (Gibson, 2011). Food fortification is a proven and preferred strategy in the prevention and management of micronutrient deficiencies. It is effective, cost effective, has the potential to achieve high coverage and has been tested in many rigorous research studies (REACH, 2011). Strong evidence exists that daily iron supplementation improves haemoglobin concentrations and iron stores, and reduces the risk of anaemia, iron deficiency, and iron deficiency anaemia during pregnancy Supplementation Analysis of available supplementation programs shows that provision of micronutrient supplementation is most effective when combined with other maternal and child health interventions through primary health care systems or health care delivery systems. Vitamin A supplementation in children Integrated approaches are not only more effective, but also cheaper than stand-alone supplementation programs. Vitamin A supplements can be distributed to children aged 6–59 months through efforts such as the Expanded Program on Immunization, national health days, and special supplemental campaigns. Iron and folic acid supplementation during pregnancy Iron and folic acid supplementation during pregnancy is usually delivered through antenatal care. Fortification A systematic review including 201 studies that assessed the effect of food fortification with single, dual, or multiple micronutrients in women and children concluded that food fortification is potentially an effective strategy to address micronutrient malnutrition. Mass fortification With mass fortification at a national level, the focus is on foods that are widely consumed in constant and sufficient amounts by the majority of the target population. Examples of fortified foods in developing countries are salt (with iodine) and wheat or maize flour (with several micronutrients). Iodization of salt has been shown to significantly decrease the incidence of hypothyroidism, while folic acid-fortified flour has been shown to significantly reduce neural- tube defects and other congenital abnormalities. Lesotho Food and Nutrition Strategy and Action Plan Page 47 Home Fortification Products The following products are most commonly used and are being recommended for Lesotho, subject to field testing and confirmation of social acceptability:  Micronutrient Powder (MNP): Powdered preparation of micronutrients, which is mixed into food while cooking or into food that is ready to eat.  Lipid-Based Nutrient Supplement (LNS): Paste preparation containing vitamins, minerals, energy, protein, and essential fatty acids, which is mixed into food that is ready to eat.  Powdered Complementary Food Supplement (CFS): Powdered preparation of micronutrients that can also contain high-quality protein, essential fatty acids, amino acids, enzymes, and macro-minerals (such as calcium, magnesium, potassium or phosphorus), which is mixed into food that is ready to eat.  Complementary Food Supplement (CFS): A term used to describe the larger category of home fortification products, which includes lipid-based nutrient supplements, and powdered complementary food supplements. Multiple responses done in Lesotho to address micronutrient deficiencies The following broader and continuous strategies have been used in Lesotho to address micronutrient deficiencies, and recommended for continuation under the new strategy:  Food diversification;  Iron supplementation; and  Deworming. More detailed strategies proposed, assumptions made and the major risks foreseen under the new strategy, with respect to addressing micro-nutrient deficiencies in the Lesotho population are presented in Table 10 below. Table 10: Strategies proposed, assumptions made and the major risks foreseen in addressing micronutrient deficiencies Goal Strategies Assumptions Risks Goal 1: To reduce anaemia prevalence in children (6- 59 months) from 50.8% to 20% 1. Promote food fortification and micronutrient supplementation. 2. Provide and encourage nursing women and pregnant women on the use of the mother-baby pack. 3. Promote consumption of iron, vitamin C and vitamin B rich foods. 1. Mothers are accessing ANC services and willing to use the mother baby pack. 2. Private sector capacity exists and are willing to fortify. 3. Mothers and caregivers are willing to give their children the MNPs as prescribed. 4. Farmers willing to produce bio-fortified crops and livestock 1. Sharing of the MNPs with other children or family members who are in the non-target group. 2. Private sector may find it costly to fortify and make available the fortified foods to the consumer. 3. False marketing of foods as being fortified or bio-fortified. Goal 2: To increase Vitamin A coverage for 1. Capacitate ECCD centres, and village 1. All VHWs are willing to encourage 1. Stock outs of Vitamin A at health facilities Lesotho Food and Nutrition Strategy and Action Plan Page 48 Goal Strategies Assumptions Risks children 6-59 months from 32.7% to 60% by 2023 health workers on micro nutrients supplementation. 2. Encourage mothers to take their children for vitamin A supplementation from 6-59 months during ANC and post-natal visits mothers to take their children for vitamin A supplementation. 2. ECCD teachers are willing to monitor the Vitamin A supplementation status of children attending their facilities. 3. Vitamin A will be available and accessible to all children who need it may discourage compliance. 2. Vitamin A supplementation may be associated with illnesses that may occur after the provision of the supplement Goal 3: To increase the proportion of children 6-23 months consuming foods rich in vitamin A from 60.5% to 85% by 2023 1. Promote production and consumption of Vitamin A rich foods 1. Service providers and Mothers will be willing to participate in the promotion 1. Climate change and weather conditions might affect production Goal 4: To increase the proportion of households with iodised salt from 92.9% to 100% in 2023 1. Review and enforce the national regulation for salt iodisation. 2. Raise awareness at community level on the importance of consuming iodised salt. 1. The relevant industries are compliant to salt iodisation. 2. Communities are willing to change their salt preferences. 3. Availability of iodine test kits when in need 1. Some segments of the population may not have the money to purchase iodised salt. 2. Private sector may not have the testing equipment 3. GoL may not have the capacity to monitor entry or distribution of non-iodised salt. 4. False labelling/marketing of non-iodised salt as iodised salt. 10.3. Maternal and Child Health Maternal and child health plays an important role in nutrition during the first 1000 days of a child’s life which is the window period from conception till a child turns 24 months. This window period is when interventions to prevent stunting in children under the age of five are most effective and can be reversed along with its effects on cognitive development. This is also the period during which there is frequent contact across the broad spectrum of services (e.g. immunization, growth monitoring and deworming) at all levels (national, district, local and community level) during which there are varied opportunities for education to mothers and caregivers. Advantage can also be taken of these contact opportunities to screen, identify and refer nutrition problems early for appropriate action. The prevention of HIV infection in adolescents and women of child bearing age together with early identification and treatment of HIV and at least 4 ANC visits starting at 14 weeks will increase HIV free survival and enable HIV positive mothers to exclusively breastfeed. Lesotho Food and Nutrition Strategy and Action Plan Page 49 Focus on child spacing for women of child bearing age is important to allow for adequate recovery of the mother and decreased chances of maternal malnutrition during pregnancy and of low birth weight babies. Households with fewer children under the age of five are more able to provide the minimal acceptable dietary diversity for their children. Adolescents with access to sexual, reproductive health services are enabled to make informed choices to delay the age of first pregnancy, spacing of children and promote optimal feeding for their families. The increasing problem of obesity among women, children and adolescents is an indication of the need to educate communities on the importance of exercise, eating whole foods and the dangers of processed, high sugar content and fried fast foods. The proven interventions and good practices to success of the interventions include the following44: 1. Adolescents: The prevention of unwanted pregnancies through access to family planning services limits pre-term births and number of children born with low birth weight for gestational age and subsequent sequelae. Through school based and community based platforms micronutrient supplementation may be implemented. 2. Women of Reproductive Age and Pregnant Women: individual or multiple micronutrient supplementation inclusive of iron and folic acid minimizes the occurrence of conditions such as spina bifida and hydrocephalus. The increased consumption of iodized salt has been associated with improvements in children’s intelligence scores. Lesotho has succeeded in achieving universal salt iodization. Maternal calcium supplementation has been shown to be associated with reduction in gestational hypertension and reduction in foetal retardation. 3. Neonates: Delayed cord clamping reduces the need for blood transfusion, improves the haemoglobin levels and ferritin levels up to 6 months of age and leads to an improvement in the haematocrit levels and reduces the possibility of neonatal anaemia. The practice of delayed cord clamping has been included in the BMONC strategy of Lesotho. Administration of Vitamin K reduces the likelihood of bleeding for up to 7 days and limits bleeding in procedures such as neonatal circumcision. Vitamin A supplementation has been reported beneficial to low birth weight babies in reducing their oxygen demands; this is however still to be concluded through further research. Kangaroo mother care is an affordable way of keeping neonates close to their mothers thus keeping low birth weight babies warm, and reinforces breastfeeding and support through the close contact between baby and mother. 4. Infants and Children: The promotion of breast feeding and supportive strategies to breastfeeding provides for optimal feeding of infants and children up to 6 months. Complementary feeding coupled with dietary diversity should be instituted from 6 months. The Ministry of Agriculture in Lesotho facilitates the formation of community nutrition groups where mothers share information about optimal feeding practices and also recipes for preparation of nutrient rich complementary foods using food which is locally available. Vitamin A, Zinc and Iron supplementation or multiple micronutrient supplementation also contribute to the nutritional status of children. 5. Disease Prevention and management: the cycle of infection, ill health, poor appetite and malnutrition has been long documented. Most of these infectious diseases may be prevented through enhanced WASH and immunizations. Early management of such 44 Zulfi qar A Bhutta, Jai K Das, Arjumand Rizvi, Michelle F Gaff ey, Neff Walker, Susan Horton, Patrick Webb, Anna Lartey, Robert E Black, The Lancet Nutrition Interventions Review Group, and the Maternal and Child Nutrition Study Group. Published Online June 6, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60996-4 Lesotho Food and Nutrition Strategy and Action Plan Page 50 diseases and of malnutrition leads to a reduction in child mortality. Lesotho has integrated these interventions using the IMCI approach. 6. Prevention and treatment of acute malnutrition: Integrated Management Acute Malnutrition (IMAM) has been scaled up to all health facilities in Lesotho, with efforts currently underway to improve documentation of outcomes for treatment. 7. Prevention and management of obesity. Summary of the actions 1. Increase the duration of stay after birth within the health facility to a minimum of 2 days. 2. Promote behaviour change communication on decisions on supporting post-delivery attendance, targeting fathers, immediate family members, community and religious leaders and all other influential structures. 3. Increase health education to all women of child bearing age on the importance of attending pre ANC, ANC services, facility delivery, post-natal care and family planning. 4. Create demand for immunisation of all children under five to expectant women and influential family and community members and expand coverage of EPI services especially in hard to reach areas. 5. To improve community mobilization on maternal and child health care services. 6. Strengthen the timed and targeted counselling (TTC) model to ensure that VHWs follow up women and caregivers of children under five to get to health facilities for timely immunisation services (e.g. Village Health Workers must screen the Bukana and refer to the health facility for immunization services). 7. To equip health facilities, VHWs and mothers/caregivers (individually or in groups) with skills and tools (scales, charts, mid-upper arm circumference tapes, height/length boards) for growth monitoring. 8. To strengthen the referral system for identification, treatment, counselling or other preventive intervention if growth is faltering. 9. Promote positive deviance peer support through mother support groups. 10. Promote enrolment of children in community based growth monitoring. 11. Promote the use of ANC services during pregnancy. 12. Promote behaviour change communication on decisions on maternal health, nutrition, healthy lifestyles and safe living environment targeting women of child bearing age, men, community and religious leaders and all other influential structures. 13. Inform communities and community leaders about the importance of timely ANC. 14. Health education on the importance of attending pre ANC, ANC services, facility delivery, post-natal care services and family planning. 15. Promote life skills education (e.g. adolescent sexual and reproductive health, prevent early marriage, keep girls longer in school). 16. Domesticate the SADC regional law on child marriages. 17. Develop a national adolescent nutrition information system. How Lesotho has had long experience and put a lot effort at enhancing nutrition. Strong advocacy by Her Majesty the Queen of Lesotho as the Exclusive Breastfeeding and IYCF Patron, has encouraged mothers and families from all walks of life to exclusively breastfeed their babies for the first 6 months. Exclusive breastfeeding prevalence in Lesotho is currently at 67%. In order to maintain this trend, increased emphasis on advocacy for action by high level leadership will be made and expanded to cover other critical nutrition problems such as stunting and high anaemia prevalence in mothers and children. Lesotho Food and Nutrition Strategy and Action Plan Page 51 The revitalization of VHWs since 2007 and introduction of district level nutrition cadres in the MOH structure coupled with the resulting capacity development of health staff and VHWs by the district nutritionists increased the focus on nutrition at subnational level. Working Together Efforts will be made to reinforcing that the stakeholders work together to deliver on these actions. At the central level the institution of the SUN platform and networks shall be rigorously pursued. Technical working groups shall be regularly convened and members involved in the development, follow up, review and documentation including of nutrition policies, strategies, standards and guidelines. Furthermore there has been increased multi-sectoral collaboration between structures at district level (e.g. FNCO, MAFS and MOH) around nutrition. International and local NGOs mobilize resources for community based activities around nutrition and support. At district level, as a mirror to the National Networks and platforms being formed around SUN, multi sectoral platforms and technical working groups can be reinforced at district level. The proposed strategies, assumptions and risks foreseen under maternal and child health are presented in Table 11. Table 11: Strategies proposed, assumptions made and risks foreseen in maternal and child health Goal Strategies Assumptions Risks 1.To increase the proportion of women who receive post-natal care within 2 days after delivery from 62% to at least 80% by 2023 Increase the duration of stay after birth within the health facility to a minimum of 2 days. Maternity health care facilities will have the resources to accommodate women for at least 2 days after birth The cost of staying in a health facility for 2 days after delivery may be too high for women. Promote behaviour change communication on decisions on supporting post-delivery attendance, targeting fathers, immediate family members, community and religious leaders and all other influential structures. Fathers, communities, religious leaders and influential structures will receive the messages favourably and support post-natal care attendance Conflicts may arise as a result of negative religious and cultural practices especially among resistant groups. Increase health education to all women of child bearing age on the importance of attending pre ANC, ANC services, facility delivery, post-natal care and family planning. Health facility staff and other stakeholders (e.g. health centers, schools, colleges, universities, and the work place) have the capacity and the knowledge to promote ANC and PNC attendance. Shortage of staff, knowledge, skills and resources in the different sectors that have the potential to reach women of child bearing age. 2. To increase vaccination coverage to two-thirds (from one third) and deworming coverage to 90% for children under-five years by 2023 Create demand for immunization of all children under five to expectant women and influential family and community members and expand coverage of EPI services especially in hard to reach areas. The MOH will have the resources to increase the number of EPI outreach points. Lack of resources to expand EPI coverage services To improve community mobilization on maternal and child health care Vaccines will be available to meet the demand. Reluctance to bring children for immunization due to negative Lesotho Food and Nutrition Strategy and Action Plan Page 52 Goal Strategies Assumptions Risks services. messages about vaccines resulting from adverse events after immunization. Strengthen the timed and targeted counselling (TTC) model to ensure that VHWs follow up women and caregivers of children under five to get to health facilities for timely immunization services (e.g. Village Health Workers must screen the Bukana and refer to the health facility for immunization services). Mothers will bring their children to the service delivery centers. VHWs are motivated to follow up mothers and caregivers of children under the age of five and to provide needed support. 3. To increase the coverage of growth monitoring and promotion for under- fives at community level to 95% by 2023 To equip health facilities, VHWs and mothers/caregivers (individually or in groups) with skills and tools (scales, charts, mid- upper arm circumference tapes, height/length boards) for growth monitoring. Health staff and VHWs will be motivated to use the equipment for growth monitoring. Lack of resources for capacitation of VHWs with tools and equipment. To strengthen the referral system for identification, treatment, counselling or other preventive intervention if growth is faltering. Mothers will bring children for growth monitoring even after immunization up to the age of 5 years. Interpersonal relationships among mothers/caregivers at community level affecting information sharing between mothers. Promote positive deviance peer support through mother support groups. Mothers are willing to share experiences and receive information from peers on optimal feeding practices and use it to improve their own practices. Promote enrolment of children in community based growth monitoring. 4. To increase the proportion of expectant mothers with first ANC visit within the first trimester from 41% to 60% by 2023. Promote the use of ANC services during pregnancy. Families will agree for women to attend ANC early. Cultural practices which discourage women from disclosing their pregnancy early before the pregnancy is visible. Promote behaviour change communication on decisions on maternal health, nutrition, healthy lifestyles and safe living environment targeting women of child bearing age, men, community and religious leaders and all other influential Health facilities have adequate capacity to deliver timely ANC services. Lesotho Food and Nutrition Strategy and Action Plan Page 53 Goal Strategies Assumptions Risks structures. Inform communities and community leaders about the importance of timely ANC. Health education on the importance of attending pre ANC, ANC services, facility delivery, post-natal care services and family planning. 5.To develop adolescent nutrition service guidelines and ensure at least 30% coverage of adolescent nutrition services by 2023 Promote life skills education (e.g. adolescent sexual and reproductive health, prevent early marriage, keep girls longer in school). Communities will comply with the child marriage laws and report contraventions. Cultural practices that perpetuate child marriages. Domesticate the SADC regional law on child marriages. Adolescents will be willing to attend the health services. Health services may be far or inaccessible to adolescents. Develop a national adolescent nutrition information system. There will be health staff capacitated to deal with specific adolescent issues. 10.4 Strengthening Clinical Services Clinical nutrition services have a major role to play in prevention and management of NCDs, HIV&AIDS and related opportunistic infections, as well as TB. Therefore, improved access to quality clinical services during illness is a key component of care which aims at preventing further deterioration of nutritional status and saving lives of persons affected. Currently, there is no information available regarding nutrition services at health facilities, therefore there is a need to strengthen clinical nutrition services to address the management of nutrition related diseases including promotion of healthy lifestyles. Adolescents are at a captive age for the marketing of products and adoption of unhealthy diets. They also are at the age where positive changes may result in long term adoption of healthy lifestyles. The Government of Lesotho should invest in early age interventions through legislations that promote physical activity and healthy eating in schools. (Kenya Strategy, 2012/17). Lesotho has prioritised the following and proven interventions and good practices: 1. Management of acute moderate and severe malnutrition 2. Nutrition counselling and supplementation for people with HIV&AIDS and TB 3. Prevention and management of NCDs Management of other related diseases Summary actions:  Promote social and behaviour lifestyles using multi-media channels.  Promote health screening and wellness days through various community based platforms.  Generate information on food consumption patterns, obesity, overweight and key drivers of adults’ lifestyles to inform behaviour change communication strategies.  Promote the establishment of wellness clinics with adequate equipment for screening and treatment of NCDs.  Improve the knowledge and skills of health workers for the prevention and management of NCDs. Lesotho Food and Nutrition Strategy and Action Plan Page 54  Effective monitoring of prevalence of nutrition related NCDs risk factors and supportive supervision of services delivered by wellness clinics.  Management of moderate and severe acute malnutrition in PLWHA and TB.  Raise awareness of < 2 years malnutrition as a risk factor for NCDs in health facilities and communities. How the actions shall be implemented  Advocate for prioritisation of prevention and management of NCDs and improved budgetary allocation.  Policies, regulations and laws will be in place in support of reduction of exposure to risk factors and regulate services, especially the promotion of unhealthy diets. Development of a tool kit for leaders and high level government officials for their own education and reference in social mobilization.  Following from rapid assessments of community knowledge, messages shall be developed and transmitted through print materials, electronic media, cell phones and verbal communication. The community consumption of saturated fats and the conflict of interest with commercial food outlets will require carefully prepared messages, especially for the youth. Education during the antenatal and other MCH activities, also integrate nutrition.  Guidelines that include all key target groups, including adolescents shall be developed and health promotion shall address the determinants of health and NCDs.  VHWs and CSOs shall be supported for primary prevention of NCDs.  Collaboration and coordination with Community based Organizations (CBOs and NGOs) shall be strengthened and continuously reinforced.  The vegetables and fruits are pricy for most households. In the mountain areas cold resistant strains and/or preservation are needed for year- long access. In conjunction with Ministry of Agriculture and Food security (MOAFS), food preservation and household gardens will be re-invigorated. Through support of the MOTI the MOF will exempt critical food stuffs from taxation to bring down their costs.  Referral models that enhance efficiency and equity shall be explored. All levels of NCD prevention shall have SOPs that facilitate the integrated services. Systems and mechanisms for improving services at community level. The continuum of care shall be ensured through involvement of NGOs, and private providers. How the stakeholders will work together to deliver on these: Efforts shall be directed at ensuring the stakeholders work together and are transmitting similar messages to communities. The institution of the MSP, SUN networks and technical working groups shall be reinforced at the national and district level. There is a strong attention paid to sports, especially football and athletics up to village level. The MOET in liaison with other ministries shall revive sports in schools and involve other sectors at the local level co-operate and participate in nutrition education and mobilization sessions during such activities. Health facilities shall procure screening materials, train other community based workers in their use and together screen community members as will be feasible. The proposed strategies, assumptions and risks foreseen under clinical services are summarised in Table 12. Lesotho Food and Nutrition Strategy and Action Plan Page 55 Table 12: Goals, Strategies and Assumptions for Strengthening Clinical Services Goal Strategies Assumptions Risks To increase the proportion of adult population practicing at least two or a combination of the top 5 healthy lifestyles to 50% by 2023 Promote social and behaviour lifestyles Willingness of target audience to adopt healthy lifestyles Resistance to change Promote health screening and wellness days through various community based platforms All platforms are willing and able to take-up the health screening and wellness days initiative Prioritization of curative over preventive services Lack of resources Generate information on food consumption patterns, obesity, overweight and key drivers of adults’ lifestyles There is demand and appreciation for evidence Resources will be available The socio-economic cost of behaviour change will be prohibitive Increase the proportion of health facilities providing quality nutrition services to 75% by 2023 Promote the establishment of wellness clinics with adequate equipment for screening and treatment of NCDs Communities attend wellness clinics once they are established Low motivation of the health workers Strengthen the knowledge and skills of health workers for the prevention and management of NCDs Complementary supplies for service delivery are available High staff attrition rate Effective monitoring of prevalence of nutrition related NCDs risk factors (overweight, obesity, abnormal lipids, raised blood sugar) and supportive supervision of services delivered by wellness clinics The existence of a legal framework for enforcement of supervisor observations and recommended follow-up actions Low staff motivation for quality service delivery Management of moderate and severe acute malnutrition in PLWHA Capacity and commitment for national response exist Shortage of health workers Raise awareness of < 2 years malnutrition as risk factor for NCDs in health facilities and communities Health workers are able to prioritize and set aside sufficient time to actively screen and counsel clients and their work in this regard is recognized and appreciated Low motivation Proportion of health facilities adopting food service and nutrition guidelines by 2023 Ensure nutrition services and education are implemented through institutions of special care (such as hospitals, homes for people with life- limiting illnesses, old age homes) to promote the reinforcement of nutrition practices Institutions of special care have the requisite capacity, to implement the national food services and nutrition guidelines Lack of resources Prevention and management of nutrition-related non- communicable diseases (NCDs) Lesotho Food and Nutrition Strategy and Action Plan Page 56 10.5. Food Value-Chain The evidence on the potential contribution to nutrition that investments to boost and diversify agricultural production, keep prices low, and increase incomes can make is undisputable45. Strategic investments in the food value-chain in Lesotho can play a critical role in complementing efforts to diversify household diets, let alone those of children. As the majority of the country’s population is reliant on agriculture for a livelihood, improving agricultural productivity could have the added benefit of raising household incomes that are vital for improving economic access to health services of nutrition benefit. A major immediate cause of malnutrition in infants and young children in Lesotho is the failure by households to feed these children a minimum acceptable diet (MAD). The WHO minimum acceptable diet recommendation combines dietary diversity and minimum meal frequency, and is different for breastfed and non-breastfed children. The Lesotho DHS, 2014 indicates that feeding practices of 89% of children aged 6-23 months fail to meet the minimum standards with respect to all three recommended IYCF feeding practices. Furthermore, one-third of children in this age- group do not consume foods rich in Vitamin A, and 59% do not consume iron-rich foods. These are issues of major concern. Although knowledge of the mothers and caregivers of children and support from spouses, as well as the greater family and community, play major roles in influencing child feeding outcomes, food availability, diversity and cost, play equally, if not more important roles in determining the ability of households to meet the minimum acceptable diet for their children. Without adequate diversity and meal frequency, which ensure appropriate growth and development, infants and young children are vulnerable to undernutrition, especially stunting and micronutrient deficiencies, which increase morbidity and mortality. Value chain development therefore has been included in this Food and Nutrition Strategy and Action Plan for its potential pivotal role in reversing the current negative dietary patterns observed not only in children but also in adults, where in addition to the other forms of malnutrition, poor diets are manifesting in overweight, obesity and nutrition-related NCDs. Value-chain strengthening is being championed by this Strategy in order to reduce the population that is food insecure, improve the diets of children and adults, ensure food consumed is safe and poverty is alleviated in the process. The agricultural sector can perform at its best if this Strategy and Action Plan can be fully implemented. Strategies proposed are backed by evidence not only in Lesotho but in other countries. Climate-smart agriculture such as conservation agriculture (CA), irrigation and raising of adaptable breeds of small livestock is prioritised. CA has already been tested and proven to minimise the disturbance of soil structure, composition and natural bio-diversity, as well as retain moisture, enrich the soil and drastically improve yields in Butha Buthe, Berea and Qacha’s Nek (Tebellong) among other districts (FAO, 2011. Conservation Agriculture and Sustainable Crop Intensification in Lesotho. Integrated Crop Management, Vol. 10). The proposed approach takes into account lessons from previous experience with CA, which emphasise the need to help poor farming households with assets (like rippers to promote adoption at scale) and inputs (seeds and fertiliser) to facilitate good CA practice, and the adoption of a participatory approach for social capital creation (e.g., farmer groups) and the use of trainers with a high-level of competency in CA, in order to maximise effectiveness. Whilst CA takes 3-4 years to demonstrate their full potential in increasing crop yields, thereafter CA becomes fully functional and delivers sustainable food, income and nutrition benefits (CRS, Care and World Vision, 2012. LIP III Final Report). Irrigation development is also prioritised based on the growing body of evidence from Lesotho showing that it works but under some specific conditions which are feasible. In Mohale’s Hoek, 45 Marie T Ruel, Harold Alderman, and the Maternal and Child Nutrition Study Group, 2013. Maternal and Child Nutrition 3: Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? The Lancet Series, 2013. Lesotho Food and Nutrition Strategy and Action Plan Page 57 Quithing, Thaba Tseka, Qacha’s Nek, and Mafeteng districts, a project implemented by three NGOs demonstrated that irrigation promotes resiliency in the face of climatic shocks, increases crop production (as many as 2-3 crops per year), opens opportunities for crop diversification and raises farmer incomes even when the irrigation is at small-scale and in hard conditions (CRS, Care and WVI, 2012). It also showed that when smallholder farmers are given irrigation opportunities, they diversify from maize to higher-value market-based vegetable production in their irrigated fields, and purchase the maize to supplement their consumption requirements instead of growing it themselves at higher cost than buying. Similar results have been documented from other irrigation projects implemented by the Government of Lesotho including, for example, those promoted with funding from IFAD under the project titled Sustainable Agriculture and Natural Resources Management Programme, in three districts (Mafeteng, Mohale’s Hoek and Quithing) (IFAD, 2012)46. The intervention package advocated for by this Strategy is thus based on these local experiences which suggest that it should include: infrastructure development support (including rehabilitation of existing schemes, construction of new gravity-fed schemes, desilting of dams for irrigation, roof water harvesting tanks for homestead gardens), strong and intensive training of community irrigation committees on operation and maintenance, basic marketing training and mentorship support to farmers on market-based production as well as formalisation of market chains (e.g., supplying school feeding programme). Business skills training to CICs and lead farmers, to increase their skills in cost/profit analysis, price tracking, identification of new products for markets, and quality controls and grading of produce, is strongly advocated for in this FNSAP. To improve the contribution of irrigation schemes to nutrition in a direct manner, irrigating households should also receive nutrition education (integrating aspects such as importance of good nutrition, how to achieve a healthy harvest, food preparation and appropriate infant and young child feeding practices). A ToT approach is recommended for coverage. Study tours to market outlets are also recommended as an effective instrument for adult training. The agronomic and marketing trainings should be complemented with training and support on how to establish internal savings and lending schemes for financial inclusion and graduation out of poverty. In addition to convention irrigation, the strategy seeks to promote forms of irrigation that are water and input-saving such as key-hole gardens and organic farming which also addresses food safety as a preventive measure for diet related cancers. The evidence of the nutritional effect of bio-fortification (for example Vitamin A bio-fortification of orange sweet potatoes) is strong. In this respect bio-fortification is included for scaling-up in this Strategy to strengthen production and consumption of foods rich in Vitamin A, iron and zinc, using maize, beans and sweet-potatoes as the vehicles. The Strategy supports on-going efforts by the Department of Research in the MAFS to promote multiplication and adoption of NUA45 beans, and VPO5121, ZM 521 and 523 high protein maize varieties, some of which are open pollinated and facilitate adoption and sustainability of seed supply at the community level. This initiative will require collaboration of government, private sector seed producers and suppliers, NGOs and the donor community to strengthen the supply chain that will promote uptake by farmers. The Strategy seeks to promote investments in high-yielding breeds of crops (including soya-bean as an important source of protein that is free from cholesterol) and livestock. In the crop sub- sector, seeds, veins and fruit-tree seedlings recommended for adoption in the highlands, foothills and lowlands will be multiplied and distributed through the various channels available with a special focus on ensuring that an aid dependency culture is not created and sustainability is ensured by supporting the private sector distribution channels in programmes that assist poor 46 IFAD, 2012, Performance Assessment Report: Sustainable Agriculture and Natural Resources Management Programme. Lesotho Food and Nutrition Strategy and Action Plan Page 58 farmers. Improved high-yielding planting materials provide quality, climate change resilience, pest resistance and some varieties provide less maturity time (www.pannar.com visited 6/12/2017). Ministry of Forestry and Land Reclamation and NGOs (such as CRS, WV and Care) will promote the fruit tree seedling production as well as forest tree seedlings. They will train farmer groups in collaboration with Ministry of Agriculture and Food Security so as to create job opportunities for the farmers. As regards small livestock breeds, efforts will build upon on-going breed improvement programmes for sheep and mohair (Merino sheep and Angora goats), and piggery to improve farm productivity, incomes and address nutrition. Rams will be produced by capacitated farmer associations for sale to other farmers to reduce dependency from South Africa. Improved management of rangelands to address environmental, water, and agricultural productivity nexus issues will be promoted. Additional support will be provided to promote poultry production at small and medium scale with a focus on indigenous poultry species that are adaptable. Poultry production efforts will build upon on-going initiatives to promote rearing of Keokoe Chickens for the supply of eggs and poultry meet so as to prevent protein energy malnutrition. The strategy seeks to expand the project producing trout fish from the new reservoirs constructed in the mountains region to diversify protein sources available to rural and urban households. To address post-harvest losses, the Strategy promotes the manufacture, distribution and adoption of improved post-harvest storage facilities and practices for crops and livestock. MAFS and the Ministry of Small Businesses, Cooperatives and Marketing will collaborate in training artisans to construct appropriate warehouses, manufacture hermetic bags and metal silos and distribute commercially to farmers. Nutrition education will be mainstreamed into all these efforts targeting farming households and the general community to raise their level of understanding on the importance of good nutrition and how to achieve it using improved diets, lifestyles and health seeking behaviour for children and adults. Ministry of Health Nutrition Unit, MAFS and FNC shall combine efforts to strengthen the knowledge of extension workers and farming households on nutrition, with special attention being given to raising their knowledge on the importance of the first 1,000 days. Special attention shall be made to reach households with children under the age of 2 years through care groups, mother to mother peer counselling groups, and dialogues with men and traditional leaders in the community using official, and informal platforms for sensitisation. Such nutrition messaging will not only foster the use of contemporary crops in food preparation, but animal source protein, indigenous orphan crops, and wild vegetables that are rich in micronutrients. Communities will be sensitised on how wild foods can be sustainably harvested, and included in the household meals in ways that ensure nutrients mutually reinforce each other in absorption into the body. Sustainable management of these at-risk organically-grown wild foods will be promoted, including the prevention of veld fires. The Food and Nutrition Strategy supports the education of agricultural extension officers and farming households on good agricultural practices to ensure farm to folk food safety. This will result in high nutritive value foods, free from viruses, bacteria or chemical substances which may lead to food contamination and poisoning resulting in many diseases ranging from diarrhoea to cancers ultimately resulting in death. Therefore organic farming at household which can include the use of home remedies for insect repellents shall be emphasised in the implementation of this Strategy. In addition the system of livestock disease prevention and control will be strengthened, to reinforce vaccination, treatment and isolation of diseased animals, and promote a culture of veterinary inspection of all livestock before importation or slaughter. This will prevent consumption of diseased animals (anthrax in cattle) which has been reported in the past (WHO Lesotho Food and Nutrition Strategy and Action Plan Page 59 Report, 6 March 2012)47. It will also enhance knowledge of producers on livestock disease signs and symptoms, diagnosis and treatment. The systems for prevention of illegal importation of livestock will be tightened, so will be stock theft. The value-chain development strategies, assumptions on success, and risks under each that will be managed are presented in the table below. 47 WHO Report, 2012. Suspected Anthrax Outbreak (Situation as of 06 March 2012). Lesotho Food and Nutrition Strategy and Action Plan Page 60 The proposed strategies, assumptions and risks foreseen under food value chain are presented in Table 13. Table 13: Goals, Strategies, Assumptions and Risks for Food Value Chain Goal Strategies Assumptions Risks Goal 1: To reduce the proportion of the population that is food insecure by 50% (from 25% to 12.5%) by 2023 1. Promote adoption of climate-smart agricultural practices for both crops and livestock farming by farmers (such as conservation agriculture, crop-rotation, rotational grazing, greenhouses, key- hole garden and double- digging, indigenous orphan crops) Farmers are willing to adopt new techniques that increase farm productivity Severe droughts, or heavy rains that could cause water logging, early frost and pest damage may reduce yields 2. Promote farmers’ adoption of high-yielding planting materials (seed, vines, fruit-tree seedlings), breeds for livestock and practices that increase yields while preserving soil health (organic farming) Government staff has the technical knowledge and skills to provide the needed extension support Government committed to investing in agricultural inputs to achieve food security at household and national levels Climate change may shift rainfall seasons and cause difficulties in planning planting The extension-worker to farmer ratio may reduce the coverage of extension services and the adoption rate for improved farming practices and technologies 3. Promote the manufacture, distribution and adoption of improved post-harvest storage facilities and practices for field crops and vegetables (including hermetic bags, metal silos and vegetable storage markets) Materials and artisans are available for the manufacture and distribution of improved post-harvest storage facilities Some of the farmers may be reluctant to adopt new technologies for lack of start-up resources Goal 2: To increase the proportion of the population (with special focus on children 6-23 months, adolescent girls, women of child bearing age) consuming foods rich in iron, zinc and Vitamin A by 30% by 2023 1. Promote local production, multiplication and distribution of bio- fortified beans (iron and zinc), orange fleshed sweet potato (Vitamin A), and orange maize (Vitamin A) 1. Research institutions are funded to undertake bio-fortification of crops and distribute to those who multiply 2. Commercial seed multipliers are willing to multiply the bio-fortified seeds and distribute to farmers using their channels Outbreaks of pests and diseases may affect both quality and quantity of crop and livestock production 2. Educate implementation agencies, extension 1. Consumers are willing to try bio-fortified crops 2.Insufficient capacity of seed multipliers leading Lesotho Food and Nutrition Strategy and Action Plan Page 61 Goal Strategies Assumptions Risks workers, other community- based workers and farming households about dietary diversity and the importance of preventing micronutrient deficiencies through the consumption of bio-fortified crops, animal source protein, fruits and vegetables and products 2. Implementation agencies and extension workers are capacitated to provide support to farmers to diversify production and adopt fortified crops to production of defective or nutrient- deficient bio-fortified seeds being distributed 3. Educate households and communities on appropriate post-harvest handling, storage, preservation, processing, preparation, cooking, and serving of food to prevent the loss of nutrients 3.Targeted households have minimum level of literacy required to grasp the concepts passed on through education 3.2. Targeted households are willing to embrace the new technologies 3.1.Farmers may lack financial resources to invest in new technologies 3.2.Non-availability of good quality raw materials for the manufacture of storage facilities (e.g., metal silos) 4. Identify and promote indigenous neglected and under-utilised vegetable species that are rich in nutrients (such as bobatsi, seruoe, qhela, theepe etc) 4.1.Consumer tastes and preferences are supportive of increased consumption of indigenous neglected and under-utilised vegetable species 4.2. Indigenous vegetables species survive climate change phenomenon 4.Burning of rangelands which destroys the indigenous vegetable species Goal 3: To reduce the population living under the national poverty line from 57.1% to 45% by 2023 3.1. Promote viable livelihood projects such as cottage industries whereby women and men do sewing, handicraft work, catering, poultry, piggery, fruit and vegetable production for sale 3.1. Willingness of smallholder farming households to diversify their livelihood projects 3.1.2. Government is committed to rolling out the community development model and plan to communities 3.1. Dependency syndrome could lead to project collapse after termination of support and follow-up on their performance 3.1.2. Inadequate monitoring, coaching and mentorship of projects may affect sustainability of such projects 3.2. Link smallholder farmers to viable markets and provide complementary support to commercialise farming (training on farming as a business, financial management, contract negotiation and management, formation of marketing groups, group dynamics and conflict management, group collateral, etc) 3.2.1. Private sectors is willing to do business with capacitated farmers 3.2.2. Government agencies will collaborate among themselves and with NGOs and the private sector to provide training and other support 3.2.Failure to meet quality and quantity standards needed by the market due to production constraints Goal 4: To 4.1. Promote good 4.1.Farmers have the 4.1.Low level of literacy Lesotho Food and Nutrition Strategy and Action Plan Page 62 Goal Strategies Assumptions Risks ensure all food is safe for human and animal consumption agricultural practices to ensure farm-to-folk food safety (including organic farming, proper use of pesticides, herbicides, and home remedies for insect repellents) minimum level of education required to read and understand labels on agrochemicals affects adherence to the window periods recommended for consumers for crop chemicals and livestock drugs 4.2. Provide veterinary services to producers of livestock (disease surveillance and control, vaccinations and treatment, inspections before slaughter) 4.2.Veterinary services department has sufficient resources (staff, vaccines, drugs) to do the inspections, surveillance, and treatment 4.2.Government budget cuts, resulting in limited operational resources 4.3. Increase knowledge of communities on the health risks of consuming animals that have not been inspected for diseases, and the importance of observing the mandatory window periods for chemicals for treating crops and animals 4.3.Farmers are risk- averse and willing to take advice and change their meat consumption behaviours 4.3.Cultural practices that promote communal slaughters without inspections 4.4. Strengthen the food safety inspection systems for domestic and imported foods 4.4.1 Control measures for food imports are operational at the border posts 4.4.2. Relevant ministries will deploy sufficient personnel at the border posts for inspections 4.4.Illicit trade of food products and livestock through porous borders, encouraged by corruption and weak law enforcement capacity 10.6. WASH Poor water, sanitation and hygiene (WASH) and suboptimal nutrition are important risk factors for morbidity and mortality in children less than 5 years of age (Walker 2007; Arnold 2013). The synergistic effects of infection and under-nutrition during the first thousand days of life (www.thousanddays.org) have been shown in several studies to have long-term effects on health, growth and cognitive development (Guerrant 2008; Victora 2008; Engle 2010; Walker 2011a). Safe drinking water, proper sanitation, and hygiene can prevent under nutrition and stunting by preventing the development of environmental enteropathy and diarrheal diseases (Dangour 2013). Global evidence shows that investing in improving people’s access to safe drinking water and promoting the use of improved sanitation and recommended hygiene practices (WASH) is critical for reducing diarrhoea incidence and increasing food intake and utilisation for improved nutrition. An association has been shown between improved water and sanitation and better growth outcomes in children across multiple countries (Esrey 1996; Merchant 2003; Fenn 2012; Lin 2013). A recent Cochrane review of randomised trials demonstrated a small but significant impact of hand washing and water treatment interventions on height (Dangour 2013). WASH should thus receive attention to reduce malnutrition rates. Lesotho Food and Nutrition Strategy and Action Plan Page 63 Conceptual Framework of WASH TED Lesotho supported by EU implemented a Project titled “Child Friendly, Gender Sensitive, Ecological and Sustainable School Sanitation Facilities” in the ten Lesotho districts. Globally the provision of safe water, sanitary disposal of human waste, and personal hygiene have long been known to have profound effects on human health (Bartram 2010). Despite progress in extending access to water and sanitation through the Millennium Development Goals (MDGs), over one third of the global population live in households without these basic services (Cumming 2014). The prevalence of safe hygiene practices is difficult to estimate but is likely to be even lower than for water and sanitation (Freeman 2014). The absence of safe water, sanitation and hygiene (WASH) results in a large disease burden with approximately one million preventable diarrhoeal deaths each year (Pruss-Ustun 2014) as well as a range of other infectious diseases (Bartram 2010). There is a growing body of evidence that links open defecation to poor child health through at least two mechanisms. The first and most commonly recognized mechanism is diarrhoea from digesting faeces. The second, which is only recently becoming understood, is a disorder of the intestine caused by continued faecal exposure. Diarrhoea remains a leading killer of young children, despite the availability of a simple treatment solution. Diarrhoea is a leading killer of children, accounting for approximately 8 per cent of all deaths among children under age 5 worldwide in 2016. In Lesotho it was estimated that 10% of under-five children died of diarrhoea (UNICEF, 2015). The Lancet Maternal and Child Nutrition Series estimated that hygiene and sanitation interventions implemented with 99% coverage would reduce diarrhoea incidence by 30%, which would, in turn, reduce the prevalence of stunting by only 2.4% at 36 months of age.24 A recent overview of the WASH situation in Lesotho has revealed that although access to an improved water source has increased, the proportion of households obtaining water from improved sources increased from 79% in 2009 to 84% in 2014. Gains were concentrated in urban households; the proportion of urban households with access to improved drinking water sources increased from 91% to 97%, while the proportion of rural households with access to improved drinking water sources shifted from 74% in 2009 to 77% in 2014. More than one third of households in rural areas (36.6%) spend 30 minutes or more obtaining drinking water, there’s still a need to promote rural and urban water supply. On the contrary clean water is a basic need for human life. Most households in Lesotho (87%) report that they do no treat their water prior to drinking. One in ten households boils their drinking water, making it the most commonly used water treatment. Despite the fact that a higher Lesotho Food and Nutrition Strategy and Action Plan Page 64 proportion of households in rural areas obtains water from unimproved sources compared with urban areas, water treatment is more common in urban areas. Twenty-one percent of households in the urban areas boil their drinking water compared with 7% in the rural areas. A quarter (22.8%) of rural households do not have access to an improved source of drinking water, very few treat their water properly (11.8%); thus promoting safe storage of drinking water and water treatment in the home (LDHS, 2014). Of the households that have a place for hand washing, only half have both soap and water (46%) to wash their hands. This indicates that methods of hand washing activities with soap and water needs to be improved (LDHS, 2014). WASCO with the assistance from the UN will provide water connections in every household in Urban areas and with the mutual purpose Rural Water Supply working together with the local Government and some NGOs will construct public taps and boreholes in rural areas resulting to promotion of rural and urban water supply whilst doing no harm to existing infrastructure such as roads. Ministries of Environment and local Government shall further protect the wet lands. Water quality tests in household and accessibility of water treatment equipment as well as proper education and awareness of safe storage of drinking water in communities shall be promoted through facilitation and collaboration of Ministry of Health and NGOs. Rural Water Supply supported by NGOs will implement sanitation models such as CLTS and PHAST to promote provision and use of sanitation facilities while Ministry of Health will assist in awareness creation (Table 14). In promotion of hand washing with soap water, the Ministry of Health, Local Government and Ministry of Education and Training in collaboration with the NGOs will provide hand washing facilities at all public places including schools and healthcare facilities as well as establishing WASH clubs in all schools and capacitating teachers on WASH. Table 14: Goals, strategies, Assumptions and Risks on WASH Goal Strategy Assumptions Risks 1.To increase the proportion of the population provided with access to an improved source of drinking water to 90% in rural and 100% in urban areas, and ensure all households without access treat the 1.Promote provision of safe water to rural and urban households (borehole, piped water, tap water, protection of springs with water points spring catchment) 1. There are enough water sources throughout the country 2. There is adequate expertise to identify water sources and educate the community about building water tanks, cleaning and maintaining the water 1. The topography (mountains and hard rocks) makes it expensive to access sustainable underground water sources Lesotho Food and Nutrition Strategy and Action Plan Page 65 Goal Strategy Assumptions Risks water by 2023 sources 2.To increase the proportion of the population with access to an improved sanitation facility from 47.1% to 60% and those using a sanitation facility from 73% to 85% by 2023 1. Promote Community Led Total Sanitation (CLTS) 1. Promotion of community ownership (communities decide what projects to do based on their needs and locally available materials) 2. Skills development for the community (communities are trained in construction of various projects) 1.Government continues to donate sanitation facilities in some communities; this will hinder promotion of CLTS A Lack of sustainability due to deterioration of some of local materials (thatched roofing doesn’t last and the community could easily get discouraged) 3.To increase the proportion of households with the ideal handwashing practices (water and soap) from 46% to 70% by 2023 1. Promote Participatory Hygiene and Sanitation Transformation (PHAST) 2. Mainstream handwashing in the formal education curriculum 3. Promote the local manufacturing of soap at household level 4. Advocate for a policy on the mandatory supply of water and soap for handwashing in all government institutions (including schools), and for all food handlers (including street vendors) and banning of the use of communal towels in sanitation facilities 5. Enforce provision of hand-washing facilities in all food establishments. Strengthen inspection of facilities that provide food (guest houses, caterers, hotels) 1. Fully committed and active WASH Teams exist or can be established at all levels (national, district and community levels) 2. Community willingness to adopt recommended handwashing practices 3. International WASH Day Celebrations will continue to be held 4. Availability of funds to supply water and soap for handwashing in all government institutions including schools. 5.Hand-washing laws will be in place 1. Resistance to change 2. Unavailability of financial resources to purchase or produce soap especially among the vulnerable groups 3. Inaccessibility of clean water for handwashing 4. Political will to make handwashing mandatory 5. Political will to promulgate hand- washing laws 10.7. Social Protection Lesotho already demonstrates a commitment to the life‐course approach. In addition to being intuitive and easy to understand, one of the benefits of a life‐course approach is that it allows a differentiation between social protection interventions that are primarily supportive (e.g. those aimed at the very young, school‐children and the elderly) and those that might aim at Lesotho Food and Nutrition Strategy and Action Plan Page 66 “graduation” of beneficiaries out of social assistance by linking them in to the labour-market (e.g., those aimed at the working age population, and especially at the point of transition from school to employment (National Social Protection Strategy, 2014). Maternity benefit exists for a very limited number of employees in the formal sector. But this is largely discretionary, and is open to abuse and exploitation. The child grant is currently available to a (very small) number of pregnant mothers and infants, who are classified as being in NISSA 1 or 2 category and are validated by the community fewer than 3000 in this age group at present. This is wholly insufficient coverage at such a crucial stage of the life‐course. The “first 1000 days” are absolutely critical to a child’s development and any damage done at this stage will be largely irreversible, so it is essential that a much greater number of pregnant women and infants receive a social transfer and are incentivised through this to better feed, nourish and nurture their children. All women in formal employment should have the entitlement to benefit from a legally mandated, standardised maternity benefit, funded from the Lesotho Social Security Organisation (LSSO) (NSPS, 2014). NSPS (2014) states that: All pregnant women and mothers of children under the age of 2 should receive an infant grant, as a nutrition-focussed complement to the current child grant, but offered on a universal basis and linked to particular milestone events to provide an incentive for attendance at birth counselling, facility‐supervised birth, birth registration, regular growth monitoring, vaccination, and health care. The National Strategic Development Plan envisaged just such a universal approach to improving nutrition when it recommended “Provide quality free universal primary education and nutrition. FAO has also conducted impact evaluations of CASH+ interventions. In Lesotho, for instance, an impact evaluation revealed that cash transfers (child grants), along with the provision of vegetable seeds and training on homestead gardening, had a greater impact on productive capacities, especially among labour constrained households than cash transfers alone (2017). How social protection issues will be addressed in the strategy includes the specific sub-actions highlighted in Table 15. Table 15: How to address social protection issues Action Sub-actions In-kind transfer  Specialized food transfers for women and children to safeguard maternal, infant and young child nutrition  General food distribution to safeguard nutrition Cash in kind  Money vouchers with restricted food choices and food denominated vouchers to safeguard maternal, infant and young child nutrition  Vouchers for maternal health services through which nutritional support is provided  Vouchers for child day care for children to support recommended IYCF practices  User fee removal from child health services through which nutritional support is provided Unconditional cash transfer  Cash transfer to safeguard healthy diets, particularly pregnant and lactating women School based programmes  School feeding to safeguard nutrition48  Take home rations to safeguard nutrition Conditional cash/voucher transfers  Cash/voucher transfers issued conditionally on meeting child school enrolment and attendance to safeguard nutrition  Cash/voucher transfers issued conditionally on uptake of mother to child health services to safeguard maternal and child nutrition Cash/voucher 48 Promote school feeding at ECCD (Early Childhood Care and Development) level Lesotho Food and Nutrition Strategy and Action Plan Page 67 Action Sub-actions transfers issued conditionally on attendance of mothers at nutrition education/behavior change campaigns  Social transfers for poor households, and child-headed households Public works programme  In-kind food transfers for participation in public works programmes to safeguard healthy diets for nutrition  Cash transfers for participation in public works programmes to safeguard healthy diets for good nutrition The goals, strategies, assumptions and risks associated with social protection interventions are listed in Table 16 below. Table 16: Goals, Strategies, Assumptions and Risks for Social Protection Goals Strategies Assumptions Risks 1. To increase the proportion of pregnant and nursing mothers and children who have access to health and nutrition services to 80% by 2023 1. Provide all pregnant women and mothers of children under the age of two years an infant grant as a nutrition focus complement to the current child grant as an incentive for mothers and children to receive health and nutrition services 1. Recipients understand the importance and idea behind the distribution of the infant grant and other grants (child grant, public assistance grants for the destitute) 1. Misuse of infant grant by those without other means of income generation 2. To increase knowledge and appreciation of the importance of nutrition to child growth and development 2. Provide nutrition education to recipients of the infant grant and other social protection programmes 2. Recipients agree on the importance of child nutrition and are willing to embrace it and promote it for their children 2. Nutrition education overtaken/ superseded by other subjects during community events 3. To improve the intake of nutritious foods among the recipients of social assistance 3. Strengthen the follow-up monitoring of the (food) spending patterns and eating habits of recipients of social assistance through a multi- sectoral approach 3.1 Empower Village Assistance Committees to work with community Nutrition and Social Protection officers in monitoring intake of nutritious food 3. There is strong commitment on the part of stakeholders to monitoring the spending patterns and eating habits of the recipients of social assistance 3. Provision of false information about household spending patterns and eating habits, which may lead to false conclusions about the nutrition intake by members Lesotho Food and Nutrition Strategy and Action Plan Page 68 Goals Strategies Assumptions Risks 4. To expand coverage by the National Information System for Social Assistance (NISSA) by 124% from 170,000 households in 2017/18 to 380,000 households by end of 2020/21 and assist those in need of good nutrition 4. Collect socioeconomic information at household and individual levels; categorise the results according to the NISSA poverty classification criteria; and share them with all relevant stakeholders, including Village Assistance Committees (VAC’s) and those involved in nutrition promotion 4. There is close cooperation between those involved in social protection, those involved in nutrition promotion, and Village Assistance Committees 4. Poor stakeholder participation in social protection and nutrition-focused initiatives/activities and events 5. Promote breastfeeding among Infant Grant recipients 5. Link the recipients of the infant grants to breastfeeding support groups for nutrition counselling on a longer-term basis 5. All recipients of Infant Grants understand\ appreciate the role of breastfeeding in early childhood development 5. Lack of appreciation of the role of good nutrition in child development, which may lead to wrong use of Child Grants and the choice not to breastfeed 10.8 Nutrition in Emergencies Since 2006, Lesotho has experienced successive climate shocks such as recurrent droughts, dry spells and flood with serious consequences for the food and nutrition security of the population. The first integrated urban and rural vulnerability assessment, undertaken in June 2017, projects a total of 306,942 people facing food insecurity from September 2017 to March 2018 (224,664 rural and 82,278 urban). These levels indicate chronic food insecurity with serious negative impact on the nutrition status of the population. In an emergency situation timely response programs are required to increase resilience of communities and their ability to access adequate food. The most commonly affected are children under the age of five and pregnant and lactating women as well as people living with HIV/AIDS and TB. Emergencies are usually characterized by rising levels of severe acute malnutrition (SAM), moderate acute malnutrition (MAM) and micronutrient deficiencies. Interventions in emergencies should be entry points to identifying and effecting long-term sustainable nutrition of the communities. Core actions proposed in order to address nutrition issues in emergencies will among other things build strong early warning information systems, the capacity of the state and non-state institutions to respond, ensure timely supply of special nutrition products, supplementary food, therapeutic foods and safe drinking water, as well as ensuring that resilience is built into the response programmes by integrating and linking emergency programmes to livelihood interventions and social safety nets/transfers (Table 17). In addressing emergency situations the health and nutrition cluster coordinated by Disaster Management Authority will provide appropriate nutrition programming support. Table 17: Goals, Strategies, Assumptions and Risks for Nutrition in Emergencies Goals Strategies Assumptions Risks Lesotho Food and Nutrition Strategy and Action Plan Page 69 To ensure timely access to adequately nutritious food for people affected by emergencies. 1. Strengthen Lesotho early warning information systems by including food security and nutritional assessment. Commitment of time and technical expertise towards nutrition emergency preparedness activities Government, UN agencies and NGOs are able mobilise the resources to procure commodities in advance and store contingency stocks Emergencies occur before sector plans are in place 2. Strengthen the capacity of Government, UN agencies and NGOs to respond to nutrition and nutrition related early warning information about potential shocks. 3. Ensure availability of specialised nutrition products, supplementary food, therapeutic food, safe drinking water and water purification commodities. 4. Support integration and linkage of emergency programmes to livelihood interventions and social safety nets/transfers. Prevent deterioration of nutritional status and save lives of vulnerable groups/prevent mortality 5. Address the underlying causes of food insecurity and vulnerability Resource allocations are made for surveillance, assessments, supplements (food and micronutrients), logistic support Communities are receptive to diversifying their livelihoods Emergencies outside the expected period Political instability 6. Strengthen utilization of climate smart technologies to ensure access to nutritionally balanced diet throughout the year even during emergencies. 7. Identify and support such communities to store excess for the lean months/times of emergencies 8. Enhance livelihood diversification 9. Participatory assessments during emergencies to ensure transparency and community ownership 10. Strengthen nutrition surveillance and early warning systems during emergencies and focusing on most affected population 11. Nutrition supplementation for the vulnerable Lesotho Food and Nutrition Strategy and Action Plan Page 70 10.9. Gender Equality and Women’s Empowerment The importance of involving men in reproductive, maternal and child health and nutrition programs is increasingly recognised globally (Davis J. et al., 2016)49. In Lesotho, however, like in many other countries in southern Africa, most maternal and child health and nutrition services have not been actively engaging expectant fathers and fathers of infants and young children, and empirical evidence is scant on challenges and opportunities for involving fathers in the country. Recent studies elsewhere have explored the attitudes and beliefs of maternal and child health policymakers and practitioners regarding the benefits, challenges, risks and approaches to increasing men's involvement in maternal and child health education and clinical services. In the Pacific region, for instance, they have found that greater men's involvement would result in a range of benefits for maternal and child health and nutrition, primarily through greater access to services and interventions for women and children. Lesotho is seeking to harness these benefits by including specific strategies to promote the involvement of men in maternal and child health and nutrition interventions. Documented perceived challenges to greater father involvement in global and regional literature include sociocultural norms, difficulty engaging couples before first pregnancy, the physical layout of clinics, and health worker workloads and attitudes (Davis J. et al, 2016). The evidence also suggests a range of context-specific strategies for increasing men's involvement, including engaging boys and men early in the life-cycle, in community and clinic settings, and making health services more father-friendly through changes to clinic spaces and health worker recruitment and training. These findings suggest that increasing men's involvement in maternal and child health services may require initiatives to engage men in community and clinic settings, engage boys and men of all ages, and improve health infrastructure and service delivery to include men (Ibid). In Botswana a recent review of literature has revealed that development of a policy on paternity leave, strengthening training on male involvement; community sensitization on cultural stereotypes and harmonization of customary and common laws are critical in promoting male involvement in child care50. Promoting male involvement in child care practices for improved nutrition is one of the strategies by which the Sustainable Goal No. 5 on Gender Equality can be achieved. SDG 5 advocates for the elimination of all forms of discrimination against women and girls, ensuring universal access to sexual and reproductive health and affording women equal rights to economic resources such as land and property. Gender stereotypes on household chores, especially those that perceive the woman as the one to look after the home and children while men are breadwinners give an unfair economic entitlement to men over their spouses, and deny children the much needed care, attention and support from their fathers. 49 Davis J, Vyankandondera J, Luchters S, Simon D, Holmes W, 2016. Male Involvement in Reproductive and Maternal Health: A qualitative Study of Policymaker and practitioner Perspectives in the Pacific. Reproductive Health Journal. 2016 Jul 16; 13(1): 81. 50 Jorosi-Tshiamo WB1, Mogobe KD2, Mokotedi MT2.Afr J Reprod Health. 2013 Dec; 17(4):35-42. Male involvement in child care activities: a review of the literature in Botswana. Lesotho Food and Nutrition Strategy and Action Plan Page 71 Evidence from the USA also shows that societal and economic shifts have expanded the roles that fathers play in their families (Garfield and Isacco, 2006)51. Father involvement is associated with positive cognitive, developmental, and socio-behavioural child outcomes such as improved weight gain in preterm infants, improved breastfeeding rates, higher receptive language skills, and higher academic achievement. However, father involvement in health care has been studied little, especially among non-married, minority fathers. The Food and Nutrition Strategy and Action Plan recognises that fathers are significant part of the child's medical home and the mother’s health care decisions, and comprehensive involvement of both parents is ideal for the child's nutrition, psychological well-being and general health of not only the child but that of the mother too. Joint ANC visits with their spouses represent opportunities for the fathers to understand the importance of good nutrition in pregnancy for favourable maternal and child health outcomes, while participation of fathers in post-natal care (PNC) visits and father support groups for IYCF and maternal and child health counselling provide opportunities for the fathers to increase their involvement in the health care of their spouse and child while learning valuable information about the health and development of their child as well as the mother. The objective of this FNSAP is to promote strategies that increase fathers' involvement in, experience and satisfaction with, fathers’ participation in optimal child feeding, hygiene and health care. The strategies give special attention to identification of and addressing the most common barriers to such participation in the context of Lesotho. The strategies tackle the central role of discriminatory gender social norms in influencing the attitudes, behaviour and practices of men in Lesotho in sharing with their spouses the burden of child care, and how they support decisions of their spouses in seeking health care, improving personal and family hygiene, sanitation practices and infant and young child feeding. These decisions include those on nutrition purchasing, ensuring availability of soap and water for hand washing in the home, water treatment for household use, encouraging the washing of hands with water and soap by all family members at critical moments, the use of improved sanitation facilities, and timely utilisation of ANC and PNC services. One of the outcomes of these strategies is that the stigma attached by the family and society to men who share with their spouses the responsibility and burden of child care, and those who accompany their spouses to health facilities to receive ANC, PNC, and family planning and PMTCT services is removed. Men in Lesotho shall become free to talk about positive practices, their satisfaction with the experiences in supporting their spouses, and become proud role models on it in the community. Childcare will no longer be perceived as a woman’s chore but that which their spouses understand to be a shared responsibility not only for the nutrition, health and welfare of the child, but that of the mother or female caregiver as well. This relationships will bring positive benefits in improved gender relations, which may have additional longer-term benefits in increasing women’s space for decision-making on maternal and child health, and their exercise of control over resources, thereby ultimately contributing to reduction in gender-based violence, child-abuse, and morbidity of the child and mother. The FNSAP therefore makes it explicit that such societal changes can only come if efforts are exerted at, among others: creating awareness on discriminatory gender social norms in relation to IYCF, hygiene and healthcare targeting community leaders and their communities; promoting male involvement in IYCF, hygiene and health care; and promoting the advocacy on 51 Garfield CF1, and Isacco A., 2006. Fathers and the well-child visit. Pediatrics Journal. 2006 Apr;117(4):e637- 45. Lesotho Food and Nutrition Strategy and Action Plan Page 72 breastfeeding at all levels, leveraging on the already on-going excellent initiatives by Her Majesty. The strategy further recognises the equally important contribution that efforts to increase the coverage of women of child-bearing age and caregivers of under-fives with access to appropriate labour-saving technologies for food production, processing, preservation and preparation, as well as water supply and purification can make towards releasing more time for quality child care, maternal and child health and nutrition, and have positive spinoffs in improving the general welfare of the families. It therefore prioritises strategies that promote: women’s access to labour- saving devices and technologies at the household level focusing on food production, processing, preservation and preparation; access to piped water for household use and farming; sensitisation of women and men on available labour-saving technologies and promote access to these by women; support technology research institutes, and vocational schools to develop, manufacture and disseminate labour-saving technological devices targeting women; and compulsory ANC, PNC and PMTCT attendance for couples. These technological devices include: community hand mills for cereals; hand-sewing machines to speed up sewing; fuel-saving stoves (e.g., Nkokonono Rocket Stove) which does not produce smoke and can be used indoors and outdoors without need for a chimney; heat retaining devices that save energy in food preparation (such as the Wonder Bag or Wonder Box Cooker); dollar lamps for charging cell-phones. Some of the labour and energy-saving devices are being produced and distributed already in Lesotho by Technologies for Economic Development. The academia and research institutions shall be supported to innovate and alleviate women’s load in farming, through designing and producing more culturally appropriate women’s devices that revolutionise current approaches to crop protection, management and harvesting. In Lesotho this is very relevant as most men are outside the country and women are the ones doing most of the farming activities. The Ministry of Health (Nutrition Unit), with support from FNCO, the Ministry of Gender, Youth and Sports Recreation, the Ministry of Social Development (Community Development Department), MAFS, and relevant UN agencies and local NGOs working in the targeted areas, will champion the implementation of these strategies by coming together to plan the best approaches, curriculum, community mobilisation strategies and delivery methods for promoting them. They will form male nutrition clubs and equip them with relevant knowledge and skills on food and nutrition, as well as maternal and child health, how to empower women to make decisions on their own health, importance of improved personal, family and environmental hygiene, the role of spousal support in child care, among other issues as already highlighted above. They will promote gender dialogues in the community aiming to educate family members, local leaders and community members on the dangers on maternal and child health and nutrition of discriminatory gender socialisation norms related to food, nutrition and health. These dialogues will seek to identify and better understand the barriers to male involvement in child care, ANC, PNC and PMTC services, positive experiences among those who do so, and ways in which the stigma associated with this can be removed in the community. These forums will also be used to promote awareness on labour-saving technologies that can reduce the burden on women (and men) in undertaking household chores, farming, food processing and preparation, among other related activities. In addition, stereotypes associated with expectant fathers and fathers of infant and young children accompanying their spouses to health facilities for joint counselling and other service provision, which cause negative attitudes among health workers, will be dealt with by educating all health staff on the advantages of this practice so that they are sensitive to the concerns of Lesotho Food and Nutrition Strategy and Action Plan Page 73 both men and women and effectively encourage the practice until it becomes the norm in society. The Ministry of Health, through the Nutrition Unit will work closely with the management of health institutions, and other organisations that own or are funding health facilities to agree on how to mainstream father-friendliness in health service delivery (including changes that may be required in infrastructure layout to encourage male participation) into the training curricula for health professionals and those who are designing the construction of new facilities. The strategies, assumptions and risks envisaged under the gender equality key result area of the FNSAP are summarised in Table 18 below. Table 18: Goals, Strategies, Assumptions and Risks for Gender Equality and Women’s Empowerment Goal Strategies Assumptions Risks Goal 1: To increase the proportion of mothers and care givers of children 0- 23 months whose spouses are involved in optimal child feeding, hygiene and health care to 80% by 2023 1. Create awareness on discriminatory gender social norms in relation to IYCF, hygiene and health care targeting health workers, community leaders and their communities 1. Community leaders will disseminate information on food and nutrition during public gathering, funeral services and any other ceremonies. 2. Combined platforms can be organised for interaction and passing the message on to other community members that did not attend the public gathering. 3. The layout of health facilities will enable men to accompany wives for health services. 4. Health worker attitude towards male involvement can be improved. Community leaders may not be able to articulate the nutrition issues well Males are not allowed to enter in a room where by a woman has just given birth (ka-motsoetseng) due to cultural norms 2. Promote male involvement in IYCF, hygiene and health care Males will realise the importance of father’s roles in food and nutrition 2 and join father support groups on IYCF, hygiene and health care Attendance of males in nutrition clubs will not be effective, due to lack of patience 3. Promote the advocacy on breastfeeding at all levels, leveraging on the on-going initiatives by Her Majesty Initiatives by Her Majesty will continue during the period of implementing the strategy Lack of funding to support initiatives by Her Majesty Goal 2: To increase the coverage of women of child- bearing age and caregivers of under- 1. Promote women’s access to labour-saving devices and technologies at the household level Women and their spouses have the financial means to purchase the labour- saving devices 1. Quality of the technologies may not be durable 2. Men will not read IEC Lesotho Food and Nutrition Strategy and Action Plan Page 74 fives with access to appropriate labour- saving technologies for food production, processing, preservation and preparation, as well as water supply and purification to 40% by 2023 focusing food production, processing, preservation and preparation materials issued to them 3. Women not willing to disclose knowledge about ANC and post-natal attendance 2. Promote access to piped water for household use and farming Water resources are available and households are willing to contribute to installation and operations and maintenance Climate-change induced severe droughts reduce surface and ground water resources 3. Support technology research institutes, and vocational schools to develop, manufacture and disseminate labour-saving technologies targeting women Assuming that research institutes and vocational training centres have this mandate High cost of raw materials prohibits new entrants into the manufacture of the technology 4. To promote compulsory ANC, PNC and PMTCT attendance for couples 1. Men are willing to learn from other males 2. Men will join their partners in ANC and post-natal attendance programmes 2. Women not willing to disclose knowledge about ANC and post-natal attendance. Goal 3: To increase the proportion of women who participate in decisions on own health care, major household purchases and visit to family or relatives from 65% to 80% by 2023 1. Empower women to make their own decisions about their health care and major household purchases 1. Women will be brave enough to make their own their decisions 2. Males will appreciate the decisions made by their spouses Women not financially secure to then access health services 2. Sensitize families about sharing household responsibilities Men are willing share the burden of child care and are available Migration of men for jobs outside the country 10.10. Capacity building Bringing organizational capacity up to scale to deliver essential services and programs is one of the continual challenges of the nutrition sector in Lesotho. Despite various efforts undertaken by different sectors to up-scale nutrition in Lesotho, evidence has shown that there is lack of knowledge and capacity to achieve the set food and nutrition goals and objectives (FNCO, Lesotho Food and Nutrition Security Coordination Capacity Assessment Report, 2018). Lesotho Food and Nutrition Strategy and Action Plan Page 75 The scope of capacity building is broad but all is geared towards increasing the ability of the institutions involved in the nutrition multi-sectoral approach to nutrition to fulfil their organizational mandates with respect to food and nutrition security in an effective manner. Even with limited resources, capacitated organizations should be able to address the food and nutrition challenges and critical issues faced by communities through efficient management. However, the use of resources at national and sub-national level, and within and outside these organisations, is also a critical factor. One way to use resources wisely is through periodic training of staff, stakeholders and board members. In a rapidly changing environment, upgrading skills and revamping established procedures can help stretch limited resources. However, the ability to link indicators of capacity to overall performance is crucial to strengthening any sector. Although enhancing capacity is not synonymous with building healthy communities, it creates safe and productive communities where people can work, live, play, and develop their potentials. In Lesotho the FNCO in its capacity as a coordinating entity, does not have the human resources or mandate to implement programmes at the community level (MQSUN Report, 2015). (s Sectors ministries and NGOs serve as the primary implementers of nutrition programmes, including nutrition-sensitive approaches, in partnership with private sector partners, parastatals and local authorities). Therefore, the FNCO should facilitate the efficient utilisation of community-based human resources for nutrition through multi-sectoral collaboration. Community-based cadres, such as MoAFS home economics assistants and MoH village health workers, present opportunities to leverage existing human resources to meet shared food and nutrition objectives. In addition, food-based approaches are recommended for the improvement of complementary feeding and community-based growth monitoring and promotion. The delivery mechanisms and structures for these need to be strengthened in relation to new thinking, concepts, approaches, policies, guidelines, protocols and tools for implementing both nutrition-specific and nutrition- sensitive interventions. Agriculture is part and parcel of nutrition-sensitive approaches to combating malnutrition at community level. The MoAFS home economics assistant cadre are salaried government employees working at the grassroots sub-centre level. In order to bridge the gap between the community and health facility, home economics assistants should work closely with health facility staff to provide nutrition education, promote complementary feeding, conduct food demonstrations, food preparation techniques, and counselling to new mothers. However, this cadre requires refresher training to help ease the workload of the nurses. In addition, stakeholders reported that MoET Early Child Care and Development (ECCD) caregivers require further training in food and nutrition during their basic training. MoET teachers also require additional practical trainings related to food and nutrition. The ECCD caregivers (like the home economics assistants) can offer support to facility staff, and they may also serve as a resource to deliver practical training to teachers should their cadre be sufficiently staffed and appropriately trained on nutrition. Lesotho has a formal nutrition degree programme at the National University of Lesotho (NUL). The Faculty of Health Sciences was established in 2002 and the Department of Nutrition was established in 2003. The programme provides pre-service training for BSc candidates in Nutrition, Food Science, Clinical Nutrition and Community. The majority of existing nutritionists and home economists are trained. There are 20 to 25 graduates over a 3- to 4-year period. The graduates are employed mainly by the Government such as MoH, MAFS, FNCO, MoET, and also by NGOs. However, most of NUL graduates are not being fully utilized and many are unemployed. The goals, strategies, assumptions and risks envisaged under the Capacity building of Food and Nutrition multi-sectoral Coordination are presented in Table 19 below. Table 19: Goals, Strategies, Assumptions and Risks for Capacity Building Result Area Goal Strategies Assumptions Risks 1. To fully 1. Upgrade and 1. The government and 1.Funding may not be Lesotho Food and Nutrition Strategy and Action Plan Page 76 Goal Strategies Assumptions Risks establish52, strengthen53 and empower the multi- sectoral food and nutrition coordinating institutional framework at national, district and community levels by 2023 establish the Commission / Authority to provide strategic leadership in the scaling-up of nutrition. development partners will provide adequate technical and financial support for the implementation of the nutrition strategy. 2. Government will appreciate the policy and strategy as a means of attaining their commitment to scaling up nutrition movement of which Lesotho is a member 3. NSDP will prioritize nutrition and integrate it into all sectors. 4. The King being a Nutrition Champion in Africa may act as a source of inspiration, awareness and political commitment. 5.The developed instruments including policy, strategy and other tools may uplift the morale of the staff at FNCO and other stakeholders to implement quality nutrition interventions available 2.Political support may be complicit 3.People might not be inspired to implement quality work 2. Develop and strengthen operational systems for the new Food and Nutrition Commission (FNC) including introduction of an effective performance management. 3. Strengthen the institutional capacity of Food and Nutrition Commission/Authority in planning, implementation, monitoring and reporting through recruitment and placement of nutritionists and other professionals according to the proposed structure. 4. Train and deploy a nutritionist cadre in every sector ministry. 5. Empower staff of key stakeholders at national, district, and community levels including FNCO staff (e.g., through in-service training, mentorship and staff exchange programmes, and long- term training). 6. Empower community organisations, community members, community leaders and families through social mobilisation, behaviour change communication and nutrition education. 52 Including recruitment of nutrition officers at community level. Also includes an activity “capacity assessments in nutrition, health and education”. Ensuring that FNCO has a critical mass of staff and skills effectively driving its mandate. 53 Development of operational systems, management, finance, HR, Accounting systems for new structures. Lesotho Food and Nutrition Strategy and Action Plan Page 77 10.11. Enabling environment Coordinated multi-sectoral approach to planning and implementation of nutrition has been constrained by institutional capacity constraints relating to the nascent but emerging structure of the coordinating body, non-readiness of sectoral structures to be coordinated and fragmented approaches compounded by uncoordinated donor support with competing priorities (FNCO, Food and Nutrition Security Coordination Capacity Assessment Report, 2018). Up-to-date evidence for nutrition and documentation of best practices has been almost non-existent with reliance on periodic 5-year demographic health surveys to assess progress on indicators. Enabling environment for nutrition as defined by, Gillespie et al in the Lancet series 2013 is the “political and policy processes that build and sustain momentum for the effective implementation of actions that reduce undernutrition”54. The Lancet series further illustrated three critical factors for building and sustaining an enabling environment for nutrition, namely politics and governance (including vertical and horizontal coherence within and among sectors and stakeholders, positive contributions from the private sector and civil society, and strengthening accountability); knowledge and evidence (including the generation, framing, communication, and use of different forms of nutrition-relevant data, evidence, and knowledge); and individual, organizational, and systemic capacity and financial resources1. Human capital is the foundation of social and economic development, as articulated in the African Agenda 2063 and the Sustainable Development Goals (SDGs). Improved nutritional status of people has a direct impact on economic performance through increased productivity and enhanced national comparative advantage. In order for Lesotho to maximize its present and future economic prospects, there is an urgent need for sustainable, cost-effective interventions that address the nutritional situation of all the members of its society. Lesotho like other countries with high levels of stunting prevalence and micronutrient deficiencies embraces the concept of enabling environment for nutrition to delivery better nutrition outcomes. The country therefore, recognizes the need for building of an enabling environment at national and district levels as health and community facilities. This will facilitate the programming, coordinating and implementing of the various nutrition-specific and nutrition- sensitive priority interventions in a lifecycle approach. There is a growing acknowledgment that enabling environments are critical in addressing all forms of malnutrition. However, little evidence exists in the effectiveness of the enabling environment. In contrast, such environments may be neutral or disabling for nutrition. Many underlying factors, processes and environments hinder achievement of food and nutrition security even though meant to enhance them in the first place due to the absence of context specificity in the solutions devised. Nutrition-sensitive programmes often have low coverage, poor targeting and poor quality, convergence and intensity of service delivery. Political instability may and certain times characterize a disabling environment for nutrition. There has been a great body of evidence that investing in nutrition increases productivity and economic growth. The economic costs of malnutrition are very high, the Cost Hunger Lesotho Study conducted in 2016 revealed that 7.3 percent of the GDP which is equivalent to 1,9 billion Maluti (USD 292 million) is lost yearly due to malnutrition. Whilst the costs of doing nothing are high the costs for investing in nutrition are equally high, therefore by having the prevalence of child undernutrition 54.Gillespie, S, Haddad, L, Mannar, V, Nisbett, N, Menon, P. The politics of reducing malnutrition: Building commitment and accelerating progress. Lancet 2013;382:552– 69. Lesotho Food and Nutrition Strategy and Action Plan Page 78 by 2025, Lesotho stands to save 1.8 billion maloti (US$$186 million), while saving 2.8 billion maloti (US$$292 million) should Lesotho reach the African Union targets of reducing stunting to 10 percent and underweight by 5 percent by 2025. Evidence also shows that an increase in government engagement and ownership of nutrition as a development issue worth addressing leads to improved nutrition as in the case of Senegal. If Lesotho is to improve nutrition it will be critical to prioritize nutrition and demonstrate their commitment with policies, human and financial resources, and legal frameworks including equitable rights. Political will must be reflected through financial support, particularly in national budgets and at sub-national levels in decentralized contexts. Accountability in nutrition is often conceived solely in terms of having the right data available at a national level. · Research by the Transform Nutrition consortium has shown the benefits of data on government commitment; real time data available to increase health worker responsiveness; and the potential opportunities and constraints to greater community involvement in monitoring the delivery of health and nutrition services. Effective multi-sectoral coordination along with collaborative planning and programming across sectors at national, regional, and local levels are necessary to accelerate and sustain nutrition improvements55. Several countries in the region have different legal and policy frameworks with particular distinction made between nutrition-specific and nutrition-sensitive laws, policies, strategies and plans (Meerman.J, 2008). As stated above, nutrition issues are not neatly limited within a single sector (Harris.J, et. al, 2012). Hence, a need exists for coordinated nutrition-related policies that will call for governments to put in place new institutional frameworks, dedicated budgets, tax breaks (or other incentives) for private-sector investment, and in some cases substantial changes in operational responsibilities and processes. Through enhanced coordination among government departments, civil sectors and other governance institutions policies are more likely to be successful. Evidence from Lesotho’s Experience with Multi-Stakeholder Programmes  Child nutrition and household food security project (1990’s). Housed in the Ministry of Health with UNICEF and World Bank support and implemented in the districts of Qacha’s Nek and Quthing. This multisectoral project was implemented through existing GOL development structures of Ministry of Local Government. This use of these structures was a critical success factor for this initiative. These structures operated long after project ended, though with limited impact on reducing malnutrition.  Southern African Food and Nutrition Project (2007). World Vision Integrated Project operating in Area development programmes sites in 3 districts (Maseru, Mohale’shoek and Botha Bothe). The delivery of nutrition interventions was based on community positive deviance approach recognizing that poor feeding practices undermine nutritional status of children. This was limited by technical guidance for its implementation and did not observe reductions in malnutrition due to its short duration.  Joint UN Nutrition Project (2010). The project used an integrated approach and with multisectoral focus to reducing stunting. The project saw partial successes in positive deviance approach, establishment of community vegetable gardens and ECCD linkages with child survival activities. The project was limited in strengthening linkages between malnutrition rehabilitation activities (health services, community and home-based programmes. Though multisectoral, government ownership was limited and vertical implementation continued to undermine programme implementation. 55 The World Bank (2013). Improving nutrition through multi-sectoral nutrition approaches. Washington, DC:The World Bank Lesotho Food and Nutrition Strategy and Action Plan Page 79 International Experience The countries below have used a mix of multisectoral approaches for food and nutrition interventions, the past decade with positive experiences:  In Peru: used a multisectoral approach coordinated at the supra-sectoral level around 2006, but then by line ministries with active support of the countries president focusing on nutrition specific and sensitive interventions using performance based budgeting and results based incentives to local areas (Conditional cash transfers).  Brazil: used the convergence approach of multisectoral interventions in targeted areas with sustained presidential commitment generating local government activity through target-based financial incentives.  Bangladesh: mainstreamed nutrition into each of the health sector services while coordinating multisectoral nutrition activity through a steering committee, however terminated community-based component that was coupled with an intersectoral element.  Malawi: based on an integrated approach all types of underlying causes of malnutrition were addressed. Food security was improved through dietary diversification, inadequate care was addressed by improving infant and child feeding practices which included promotion of exclusive breastfeeding and appropriate complementary feeding, increasing knowledge and practices related to micronutrients and health. Insufficient health services were improved by the promotion and support of immunization. Unhealthy environment as addressed by the provision and support of protected water and latrines.  Senegal: a country on track with MDG1 target Nutrition programme was used to reach MDG 1. Community based nutrition (growth monitoring and counselling, cooking demonstrations, home visits and follow-ups), multisectoral support for nutrition (coordinated by several ministries) and support implementation and monitoring & evaluation of national policy. Core actions to create an enabling environment for food and nutrition security include the following: Stronger national and political commitment  The NSDP should clearly state the Food and Nutrition implementation element as the key factor for country’s social and economic development.  Leadership commitment and appreciation to improved Food and Nutrition will highly emphasize the importance of nutrition as well as reduce the consequences of malnutrition in the country.  Encouraging an increased commitment to nutrition from development partners. Increasing funding for food and nutrition security  The government and partners should focus on additional resources in the country to scale up evidenced based high impact food and nutrition security interventions. Stronger monitoring and evaluation of food and nutrition interventions  Nutrition stakeholders should have clear structural national monitoring and evaluation tools that will help for effective planning and reporting. Stronger coordination mechanisms in support of integrated multi-sectoral approaches  Strengthen food and nutrition coordination and partnerships among nutrition stakeholders in order to improve the impact of nutrition activities implemented across the sectors. Lesotho Food and Nutrition Strategy and Action Plan Page 80 Strengthened policy and legislative framework to support implementation and enforcement of standards  Nutrition should be integrated in various policy documents e.g. it should appear in the National Constitution, NSDP, etc.  Policies and guidelines specific for food and nutrition security should be in place for implementation, including IYCF, HIV/AIDS, food fortification and micronutrient supplementation.  Provide laws in which nutrition information will be controlled in order to reduce false information that may be disseminated with regard to issues of nutrition, so as to change people’s behaviour and attitude towards nutrition.  Currently we have a school feeding policy that only caters for primary level; therefore there has to be development of other policies that cover other institutions such as public and private in order to contribute to the overall nutrition efforts e.g. Conducting a situation analysis on school, institutional feeding and reviewing existing guidelines.  Ensure availability of clear guidelines/strategies to prevent and provide guidance on prevention and control measures of the non- communicable diseases.  There should be policies, laws and regulations that determine the activities that prevent deterioration of nutritional status and save lives of vulnerable groups e.g. in cases of disease outbreaks or severe illnesses.  There should be specific and relevant set of policies and legal frameworks in place to ensure provision of quality food and nutrition services in the country.  The strengthening of WASH policy through enforcement of laws regarding hygiene, washing of hands and provision of safe and clean water should be in place.  Strengthening enforcement of food safety laws and regulations.  Enactment of anti-child marriage laws and enforced in order to eliminate child marriages, prevent teenage pregnancies as well as reduce malnutrition.  Consumer protection laws and regulations should be in place with regards to foods produced for consumption and for sales.  Strengthening of safety net policy, strategy and package e.g. for the poor, cash transfers, child grants. Enabling changes in socio-cultural norms and behaviours through nutrition education and intensification of social behaviour change communication  Strengthening gender equality and sensitisation of young and adult men to take up responsibilities pertaining to child care with regard to nutrition e.g. feeding a child should not be a woman’s responsibility alone.  Nutrition education should be incorporated in the curriculum and enforced at all educational levels and in all schools. Lesotho Food and Nutrition Strategy and Action Plan Page 81  Another enabling factor is nutrition education on consumption of healthy foods to all people including pregnant women and strengthens supplementation of iron and folate to pregnant women.  There should be a clear sustainable nutrition advocacy plan that will pave a way for nutrition strategy. The goals, strategies, assumptions and risks related to enabling environment are summarised in Table 20 below. Table 20: Goals, Strategies, Assumptions and Risks for Capacity Building Result Area Goal Strategies Assumptions Risks 1. To increase resource allocation to nutrition to 3% of national budget and mobilise funding from development partners by 2023, to meet the scaling-up of nutrition commitment made by the country in 201456 1.1 Advocate for every ministry, department, government parastatals, civil society and development partners to set aside a minimum of 3% of their annual budget to support multi-sectoral nutrition interventions. 1. Government commitment will be motivated by progress achieved by FNCO and partners in developing implementation instruments for scaling- up. 2. Government will fund scaling up of nutrition efforts 1. Government may not allocate sufficient resources to nutrition. 2. Without financial support the multi- sectoral nutrition strategy will not be implemented as envisaged. 1.2 To advocate for development partners to commit financial resources to support the implementation of the nutrition policy and strategy. 1. Development partners are committed to supporting scaling up nutrition 2. New development partners to support nutrition will be identified 1. Development partners may not commit to the government agenda on nutrition. 2. To develop new, review existing, and fully enforce food and nutrition legal frameworks (such as food fortification law, code of marketing of breastmilk substitutes, monitoring of salt iodisation, maternity protection, establishment of FNCO commission/authority, food safety law), guidelines and standards by 2020. 2.1 To establish a Legal Framework Task Team which will incorporate lawyers and planners and Human Resources professional to review and facilitate development of food and nutrition laws. 1. Stakeholders will understand the importance of mainstreaming nutrition into their sector plans and strategies 2. Legal department will support development of new laws Development and approval of laws might take too long Financial and human resources might not be available 2.2 To review and mainstream nutrition into all sector policies and strategies. Sectors are willing to embrace food and nutrition security within their policies and plans Addressing nutrition is viewed as Ministry of Health sole mandate 2.3 Legal Framework Task Team to facilitate and guide the establishment of FNCO as an authority/commission The political leadership views nutrition as high priority in NDP and will continue to do so Institutional jealousies thwart efforts to elevate FNCO to authority/commission status 2.4 To develop mechanisms of enforcement of food and Skills and expertise available for drafting legislation Understaffing of legal drafting team and competing 56 Advocacy, resource mobilisation, sensitisation Lesotho Food and Nutrition Strategy and Action Plan Page 82 Goal Strategies Assumptions Risks nutrition legislations (e.g., careful examination of food standards in Trade) priorities for these experts crowd out food and nutrition security in legislative processes 3. To fully integrate nutrition into existing and new national and sectoral policies, strategies, plans and curricula by 2023 3.1 Mainstream nutrition into existing national and sectoral plans Processes for the review of existing national and sectoral plans are under way during the tenure of the FNSAP Reluctance by sectors to add extra responsibilities due to low under-funding 3.2 To establish a curriculum task team composed of members of academia, nutritionists from key ministries to support the on-going process of curriculum review in the Ministry of Education and Training. Willingness by Education Sector to incorporate new aspects of food and nutrition security into the new curriculum Shortage of qualified teachers to teach an expanded curriculum 4. To develop and implement a new nutrition information system for nutrition by December 2019 4.1 Strengthen the surveillance team by recruiting all key stakeholders and agree on a programme of work and schedule of activities. Stakeholders willing to work together on data generation, interpretation, messaging and use in improving food and nutrition programming Poorly trained or demotivated staff 4.2 Stakeholders should report to FNCO on all their activities using an agreed template Stakeholders have systems to produce activity reports Difficulties sending data from sites to central locations in a timely and reliable manner Lack of data quality procedures to ensure proper input and analysis of data 4.3 Disseminate information to all key stakeholders Stakeholders willing to share information Reports not produced in a timely manner Stakeholders not acting on information generated by the systems 4.4 Increase other sources of data through nutrition studies and research Expertise for conducting research and nutrition studies available Uncertainty and instability of funding 11 IMPLEMENTATION PLAN 11.1. Infant and Young Child Feeding Lesotho Food and Nutrition Strategy and Action Plan Page 83 The National Food and Nutrition Strategy is only effective when implemented. There are a number of goals that clearly highlight strategies and several sub-activities under each strategy. The strategy identifies immediate short term actions, medium term and long term actions. Short-term strategic activities (Years 1 to 2) include, the mobilisation of resources for nutrition activities, procurement and distribution of complementary job aids and working tools (e.g., anthropometric equipment and treatment equipment). Promotion of school gardening with cooking demonstrations and nutrition education. On-going strategic activities The biggest challenge for Lesotho is high prevalence of stunting and the main focus or priority is to reduce stunting in under-five children within year 1 and 2, strengthening maternal nutrition, and community IYCF services during the first 1000 days (conception-2 years) , especially nutrition assessment, education/ counselling and support of pregnant and lactating mothers and caregivers of children under the age of two years , development and dissemination of information, education and communication materials and supplies for therapeutic foods for effective delivery of IMAM services, micronutrient supplements, deworming, iron and folate supplements and vitamin A supplements, training of fathers and communities on IYCF. Promotion and establishment of breastfeeding support groups, nutrition clubs and nutrition corners. Long-term strategic activities The development and finalization of IYCF Policy, the promotion of the code of marketing of breast milk substitutes and the updating of the guidelines to capture the WHO guidelines will be implemented in this period. 11.2. Micronutrient supplementation Short-term strategic activities: Year 1 and 2 training of health workers, community workers on home fortification using micronutrient powders. Procurement of micronutrient powders. Pilot on use of micronutrient powders. Training of caregivers and pregnant and lactating women. Resource mobilisation, sensitisation campaigns on all forms of media. On-going strategic activities: training of health workers, community workers on home fortification using micronutrient powders. Procurement of micronutrient powders. Pilot on use of micronutrient powders. Training of caregivers and pregnant and lactating women. Resource mobilisation, sensitisation campaigns on all forms of media. Routine supplementation on Vitamin A, Iron Folate and deworming tablets. Adoption of positive deviance approach. Promotion of diet diversification through establishment of homestead gardens and advocate for bio-fortification of seeds. Must have routine food inspection. Long-term strategic activities Development and enforcement of laws and legal frameworks to regulate and control food fortification and salt iodisation. 11.3. Maternal and Child Health Short-term The intent is to improve the coverage and quality of the MCH services through strategies that involve either adoption of new norms/standards and/or improving on the already on-going interventions. In order hat postnatal care is enhanced through extended stay health facility policy will have to be updated and disseminated, providers and facility managers will have to be orientated on the new schedule. VHWs have motivated ad followed up and counselled women and parents on children for immunization. They will need to be trained and through supportive supervision capacitated on targeted counselling. Training and support reference and supervision Lesotho Food and Nutrition Strategy and Action Plan Page 84 tools will need to be developed and Health Center staff orientated on the new model. For clients, families, and individuals to utilize the services and therefore increased coverage they have to be aware of the service, have knowledge on what it is and why it is essential. Target audience will have to be delineated, appropriate messages will have to be developed, appropriately packaged, and disseminated through varied channels. In this regard there will have to be advocacy with and with linkage and with the print and audio communication as well cellphone proprietors both for the dissemination as well as including nutrition and related services in their social responsibility. Initially health facilities, then VHWs will have to be appropriately equipped and the providers trained on their use where necessary. In some cases the already existent equipment will have to be upgraded and/or repaired; a maintenance plan would accompany the procurement of the equipment. Materials and curriculum for life skills education will be developed and staff in schools as well as in health facilities trained to better serve adolescents. Medium-term Improving access to services should be accompanied with an effective referral and support system. The existent referral modalities will have to be strengthened and made more user friendly. This has implications for additional logistic resources and tools for referral. The already existent resources shall therefore have to be augmented. Additional resources will have to be mobilized and the maintenance and replacement system put in place for longevity. The advocacy, education and mobilizing of communities will have to be sustained and updated based on the lessons learned as well as opportunities for new and innovative mechanisms for educating and mobilizing communities. Community members who shall serve as models for positive deviance shall be identified and supported to form and sustain per mother support groups for nutrition. Long-term As the experience on serving adolescents becomes wider, communities’ support, and service uptake by adolescents increases there will be a need to improve on the existing information collection and analysis on the status of adolescents. An adolescent nutrition information system shall be instituted and not masked under the broader HIS. The Marriage Act No.10 of 1994 section 27 makes marriage below the age of 16 years illegal. There already are on-going efforts to sensitize communities against child marriage and enforce compliance. The practice is however deep-rooted in practices that are socially perceived as culture and community leaders are reluctant to advocate against it. However, at the age of 16years the girls are not physiologically ready for child bearing and are more predisposed to the complications including nutritional (low birth weight, maternal malnutrition) that follow from early child bearing. Carefully designed messaging and avenues for advocacy as well as social mobilization against the practice and compliance with the law shall continuously be disseminated and updated. All advocacy and social mobilization shall be continued. 11.4. Clinical Services and Non-Communication Diseases The strategy has identified immediate short-term actions, medium term and those to be implemented in the long term. Since nutrition in Lesotho is currently under-funded, and no meaningful progress can be achieved in the implementation of the strategy without a significant improvement in resources and capacity. Short-term Activities that would be implemented in the short-term include: resource mobilization, institutional strengthening, recruitment of staff, strengthening of trainings for health professionals (such as Nutritionists, Dieticians, Nurses, Doctors, etc.), procurement and distribution of anthropometric equipment, NCDs screening and treatment equipment, complementary job aids and working tools. As well as development and dissemination of information, IEC materials and increasing supplies of therapeutic foods/supplements. Development of a BCC strategy on healthy lifestyles, reviewing and updating IEC/BCC materials on healthy life styles, promoting social behavioural change on healthy lifestyles using various types of mass media, carrying out social outreach activities and development of a protocol on prevention and management of NCDs. Lesotho Food and Nutrition Strategy and Action Plan Page 85 Medium-term Some of the short term actions would be on-going, therefore still implemented under medium term. These will be trainings on prevention and management of NCDs, and continuous professional development. Development of a BCC strategy on healthy lifestyles, reviewing and updating IEC/BCC materials on healthy life styles, promoting social behavioural change on healthy lifestyles using various types of mass media, carrying out social outreach activities and development of a protocol on prevention and management of NCDs. Long-term Long term – infrastructure equipping workplaces, organizations conducting health screening and wellness days, and NCDs screening (for controlling diabetes, hypertension, overweight and obesity). 11.5. Food Value-Chain Short-Term Value Chain In the short-term the MAFS will intensify sensitisation of farmers on available bio-fortified planting materials (bean and maize seed and veins for sweet potato). Promotion and protection of sustainable harvesting and consumption of indigenous neglected species (such as wild fruits and vegetables). Training of agricultural extension staff and other community based cadres and volunteers on dietary diversification and importance of preventing micro-nutrient deficiencies will also be scaled-up by the Ministry of Health in collaboration with the relevant government ministries and non-state actors on the ground. Partnerships between the research institutions and the private sector seed multipliers will be forged in order to multiply and increase the quantity of seed for bio-fortified maize and beans available to farmers. Climate adaptive agriculture shall be intensified through a ToT programme in the first year coupled with farmer organisation and capacity building on these approaches. Current projects promoting conservation agriculture will be supported to increase coverage, including provision of labour saving technologies. Improved small livestock breeds will be identified and distribution promoted through private sector and NGO distribution channels. Farmers will be trained on improved animal husbandry practices, and veterinary services will be strengthened. Medium-Term Value Chain Trained nutrition and home economics officers in the MAFS in collaboration with district nutritionists, and the Ministry of Gender, Sports and Recreation will continue nutrition education activities (through cooking demonstrations) in the medium-to-long-term. Bio-fortified crops will be mainstreamed into the government agricultural input support programmes to promote wider adoption nationwide. Promotion of climate-smart agriculture will continue and adoption will be monitored for impact and lesson learned. Private sector players will be identified and supported to locally produce improved post-harvest storage technologies (e.g., hermetic bags and metal silos) and promote distribution to farmers. Construction of vegetable market stores will be carried out as already planned by the government and selection of registered farmers who will use the markets (supplying the produce) will be done. These will also be trained on farm-to-folk food safety. Promotion of climate adaptive farming methods will continue into the medium-to long term. Lesotho Food and Nutrition Strategy and Action Plan Page 86 Commercialisation of small-holder agriculture shall create opportunities for local production to substitute imports. Market linkages will thus be critical to develop in the medium-term to take advantage of the increase in agricultural outputs, and high quality arising from enforcement of food safety standards. In the medium-term women and men with potential and interest to undertake the business of cottage industries will be capacitated for greater viability, growth and additional job creation for the poor and unemployed to raise their incomes and contribute to food and nutrition security. Long-term Value Chain In the long-term household adoption of improved storage will be assessed for efficacy and impact in relation to reduction of post-harvest losses. Cottage industries will continue to be nurtured to expand and assessed for impact on rural and urban incomes. Strengthening of livestock disease surveillance, inspections, vaccination and treatment will continue into the long term. Food safety practices will be monitored to ensure that all role-players along food value chain adhere to the set standards. Research institutions will continue to conduct research and development into new improved bio- fortified crops and labour-and energy-saving devices. The impact of the strategies on household food security, diet diversity and improved nutritional status of children under-five and their mothers will be expected to have occurred and shall therefore be assessed. 11.6. WASH Short-term Promotion of safe storage of drinking water and water treatment in the home such as chlorination, filtration, use of water storage containers with a tap for easier water access, will be implemented in a short term. This can be achieved through the use of various media platforms in the country. Medium-term Promotion of hand washing with soap and water will take a bit of time to provide through construction of the hand washing facilities/ stations at every corner of the country. Promotion of menstrual hygiene management (MHM) through provision of MHM information and menstrual hygiene materials in schools shall be scaled-up. Long-term Promotion of rural and urban water supply will take a long term implementation due to many factors involved in water connections, looking at equipment to be used, involvement of various stakeholders controlling roads, electricity lines, settlement sites and environment as large. Therefore the total water supply can be achieved in 5 years. Promotion of sanitation models (CLTS and PHAST) requires continuous education since it takes a long time to change the attitudes and beliefs of communities who now rely on government to provide sanitary facilities. 11.7. Social Protection Lesotho Food and Nutrition Strategy and Action Plan Page 87 An important long-term goal of the social protection sector in Lesotho is to improve quality of life through interventions that seek to fight poverty, deprivation, vulnerability and inequality. In order to achieve this goal, those responsible for social protection delivery will engage in efforts to facilitate improvement in the nutrition among the beneficiaries of social protection interventions. Specifically, these efforts will seek to improve the nutrition-sensitivity of all social assistance and subvention programmes, as well as livelihood promotion interventions. Short-Term Efforts will be made to induce beneficiaries of social assistance programmes to spend reasonable proportions of their grants on nutritious food. This will be achieved through improvement in the on-going sensitisation efforts led by community-based Auxiliary Social Welfare Officers. Public gatherings and grant payment days will be used as platforms for providing education/advice on desirable spending patterns. The on-going homestead gardening project (commonly known as the Keyhole Garden project) not only aim to improve the agricultural skills and farming techniques of beneficiaries, but also aim to help them and their households improve their intake of nutritious food. Prominent interventions such as the School Feeding Programme will continue to make nutritious food available to school children, especially those who come from poor backgrounds. Medium-Term Beneficiaries of livelihood promotion interventions such as the on-going Community Development initiatives and vocational skills training programmes for people with disabilities will be encouraged to improve their diets once they are able to fend for themselves. A commendable effort on those training the latter is that they provide nutritious meals for them throughout the two- year training programme that they provide. Long-Term The Community Development Model and Plan formulated by the Ministry of Social Development will provide useful tools for guiding beneficiaries of the envisaged57 livelihood promotion interventions towards improving their food intake, including satisfying their nutritional needs. 11.8 Nutrition in Emergencies The implementation plan takes into consideration Lesotho’s biggest nutrition problems currently obtaining before the onset of an emergency: (1) one in three children under five stunted; one in four persons living with HIV; (3) fifty percent prevalence of anaemia in children <2 and <5; and (4) only one out of every 10 children receives minimal meal frequency and minimal dietary diversity before the emergency (DHS 2014). Short-term strategic activities In the short term, it will be important to enhance the quality of preparedness for nutrition emergencies. Guided by the themes of the Hyogo Framework of Action (2005-2015) for disaster risk reduction, short term strategic activities will need to include: (1) the community based promotion of productivity of more nutritious foods before especially targeting populations with the highest risk; (2) Increasing demand for and access to nutritious foods through consumer knowledge and awareness campaigns including the promotion of optimal feeding practices; (3) mitigating risks associated with agriculture such as droughts, floods, heavy snow, early frost, 57 There are a number of community development projects that are already running. However, the Ministry of Social Development is in the process of using both its Community Development Model and Plan to introduce more sustainable ones. The Ministry hopes to find ways to improve existing ones by conforming them to the Model. Lesotho Food and Nutrition Strategy and Action Plan Page 88 water-borne, food-borne, and zoonotic diseases; and (4) breeding more nutritious varieties of food crops and creating a culture of risk informed nutrition practices. Coordination mechanisms between Government, UN and NGOs will need to be strengthened with all agreeing on a common set of approaches to nutrition in disasters and joint estimation of numbers of persons affected. Stakeholders should actively participate in risk mapping in nutrition sensitive sectors and agree on early warning standards to incorporate into the surveillance system. Capacity development for nutrition emergency response will need to be scaled up (e.g. for 2018, VHWs will be trained using the community-Integrated Management of Childhood Illnesses (cIMCI) package with updated, micronutrient supplementation, infant feeding promotion, screening, identification and referral guidelines). Quarterly lists of persons/numbers trained in Infant and Young Child Feeding, Nutrition Assessment and Counselling, Integrated Management of Acute Malnutrition, cIMCI and micronutrient supplementation) will be compiled and a training database of the information at MOH Nutrition department will be created and maintained. Other activities will include: establishment and documentation of all active community nutrition clubs, breastfeeding support groups; ensuring that the National Health Information System is capturing key nutrition early warning indicators such as weekly/monthly admissions for treatment of severe acute malnutrition; and orientation of district/national level technical nutrition stakeholders on DHIS2. Orientation of MOH Health Information staff on nutrition indicators and monitoring tools to follow-up on documentation of these indicators will also be done. There is a need to acknowledge / review/ document best practices and centres/districts that have done well in nutrition emergency response during previous emergencies. Engagement of communities in gender sensitive, participatory nutrition contingency planning will be carried out. The phase will also strengthen monitoring of salt iodation and iodine deficiency disorders. Capacity building on lactation management during emergency including IYCF in the context of HIV/AIDS is also important at this stage. The strategy will enable affected communities to access safe water through direct provision (in the case of drought) and through water purification tablets, soap and sanitizers (in the case of flood and heavy snow). It will also promote hygiene practices including construction of tippy taps and ensuring availability of toilet facilities for affected populations. As part of social protection the need to ensure provision of utensils and food for displaced and vulnerable groups and cash top ups where possible and relevant is emphasised. The roll-out of the strategy will also resource the provision of continued medication for displaced persons during emergencies especially including ART, hypertension, diabetic other medication. Ensure provision of food aid to vulnerable populations during emergency. Trigger indicators that need to be monitored as part of the early warning system for food and nutrition security shall be agreed upon (see example in table 21). Table 21: Examples of key indicators to be used to trigger emergency responses Nutrition situation Recommended actions Aggravating factors include the following Acute malnutrition rate >15% Or 10- 14% with aggravating factors*  Emergency food aid: general food ration  Blanket supplementary feeding  Therapeutic feeding of severely malnourished individuals  Household food insecurity;  High prevalence of HIV/AIDS;  Crude mortality rate greater than 1/10,000/day;  Under-five crude mortality rate greater than 2/10,000/day;  Epidemic of measles or Lesotho Food and Nutrition Strategy and Action Plan Page 89 Acute malnutrition rate 10-14% or 5- 9% with aggravating factors*  No general rations  Targeted supplementary feeding  Therapeutic feeding of severely malnourished whooping cough (pertussis);  High prevalence of respiratory or diarrhoea diseases;  High prevalence of pre- existing malnutrition, e.g., stunting. Acute malnutrition rate <10% with no aggravating factors  No emergency food and nutrition intervention Medium-term strategic activities In the medium term, the country will mainstream risk informed programming in all health and nutrition promotion guidance. Relevant actors will advocate with Ministry of Science and technology, National University of Lesotho and other institutions of higher learning for nutrition sensitive technologies, e.g. the current support to nutrition sensitive product development highlighted during the 2017 Science and Technology Innovation week. Promotion of drought tolerant crop farming, conservation farming, water harvesting, moisture conservation techniques, staggering of crops, enhancement of crop varieties will be pursued during this phase. Furthermore, the strategy makes provisions for supplementary feeding for livestock, introduce a livelihoods centred approach to Disaster Risk Management and draft climate change adaptation strategies. Long-term strategic activities Longer term actions include securing nutrition-sensitive communication facilities and equipment to support early warning systems prioritising marginalised and vulnerable communities. The number of stand-by helicopters will be increased to five for all districts and at least one ambulances for each hospital and this will be done in the context of overall disaster preparedness planning and readiness, and not only for food and nutrition security. Establishment of milk banks for babies who have lost their mothers during emergencies is envisaged. Baby and mother friendly nutrition and breastfeeding rooms will be established and included in infrastructure plans for safe evacuation centres. The actions shall also include securing an area for breast feeding mothers – permanent infrastructure for flood/snow prone communities to “escape” to baby friendly shelters during floods. In the longer term efforts will be directed at harnessing the potential of ICTs, by ensuring that all smart agricultural technologies developed in the future are nutrition-sensitive. Full incorporation of commodities for management of SAM and MAM as part of the government budget and supply chain with accountability mechanisms put in place to prevent mismanagement. Efficient tendering processes will be devised for commodities being purchased for emergencies. Financial management will be improved and payments to suppliers expedited. Data on nutrition will be “mined” to assess whether the minimum recommended performance indicators (coverage, recovery, defaulter, non-response and deaths) are being met. In the long term, the whole information system will be overhauled to capture data elements in tablets at health centres to enable the system that will automatically calculate indicators. Full enactment and enforcement of The Code of Breastmilk Substitutes will be done so that this becomes law. It is also expected that the Disaster Risk Reduction Policy updated using the latest nutrition contingency plan will be fully implemented. In the longer term investments will be directed towards capacitating communities and decentralizing the provision of micronutrient supplementation to Village Health Workers. Provision of height boards to all VHWs in addition to scales and MUAC tapes, and MUAC tapes to mothers will be undertaken, and the procurement will be done annually throughout the strategy Lesotho Food and Nutrition Strategy and Action Plan Page 90 period. Review and updating of policies to include adolescents in micronutrient supplementation programmes will be prioritised so shall be the incorporation of nutrition emergency in pre-service curricula of health, agriculture and education staff. Community infant feeding/nutrition support groups will be expanded to include fathers, grandmothers and grandfathers and key family members surrounding the mother. 11.9 Gender Equality and Women’s Empowerment Short-term strategic activities In the short-term, already available labour-saving technologies for women will be promoted at scale. Devices that can be manufactured locally and with available local raw materials will be prioritised for production. Small scale artisans will be trained and supported to produce them commercially and market the devices through the available channels (such as agro-dealers, hardware shops or retail chains). Women will be sensitised on the available devices and linked to the sources through existing community-based approaches. Sensitisation of leaders, communities and families on the importance of sharing responsibilities in child care will be feasible in the short-term and will be actively promoted through production of relevant IEC materials. The intervention package for supporting formation and capacitation of men-to-men IYCF support groups will be formulated and implemented building on existing initiatives in promoting male involvement in PMTCT in Lesotho. Medium-term strategic activities In the medium-term, spouses will be expected to start taking part in ANC and PNC visits and orientation and supervision of the health personnel to reduce stigma associated with men accompanying their spouses to the health facilities. Local authorities will be sensitised to promote male involvement in child care through relevant district forums. Long-term strategic activities Initiatives to empower women to make their own decisions about their health care and major household purchases will require more time as changing cultural inhibitions to women’s empowerment is unlikely to happen in the short-term. These strategies for women’s empowerment in decision-making may be conditioned by their ability earn own income and acquire education, and receive the support from their spouses and other family members, especially in the extended family. In the long-term strategies to improve accessibility of water supply at household level using piped water schemes, and electricity installation to reduce the time women spend on fuelwood collection chore can only be planned as longer-term interventions which although promoted from the first year will need to be continued and strengthened in the medium and long term. 11.10. Capacity building Short-term interventions Advocacy for food and nutrition capacity development  Capacity building and staff development (FNCO, health, agriculture, home economists and other extension workers) is a priority.  A stakeholder mapping is needed to examine current nutrition-specific and nutrition- sensitive activities to identify gaps in programming and in coverage.  Inclusion of development partner support e.g. through UN Inventory to inform strategic interventions  Development of a National Advocacy Plan and its implementation. Nutrition Coordination (FNCO, SUN) Lesotho Food and Nutrition Strategy and Action Plan Page 91 Coordination appears to be going well at the district level. In the short term, the FNCO will improve coordination at the national level, with effective mechanisms involving all stakeholders in government, development agencies, the United Nations, and the private sector. Medium-term interventions Medium-term interventions will be elaborated from the Capacity Development Plan. Long-term interventions Financial  Establishment of the National Nutrition Fund as a Repository of all Nutrition funding/ investment. Sources of funding can be as follows: Government Budget Allocations; Donor funding; and fund raising.  Tax Rebate/ incentives. Institutional Capacity  Authority of the FNCO should be strengthened, including placement and funding for the officer, and move away from a flat structure.  Advocating for a new structure and new positions.  Establishment or strengthening of a National Food and Nutrition Advisory Team, the multi-sectoral task teams and the SUN networks should also be developed, reviewed and strengthened.  Cadre Establishment for Food and Nutrition in the Public Service. Human Resource Development Absorptive capacity in the work market for nutritionists will be increased through job creation that enables the up scaling of nutrition with well trained personnel. In addition, in institutions where nutritionists are already recruited, government will embark on pre-service, in-service and on the job training programmes. Legal framework Development of legal instruments that enable support for implementation of nutrition governance (to be elaborated) will be prioritised. 11.11. Enabling environment Short-term strategic interventions Building on the commitment to the Scaling-Up Nutrition (SUN) movement and the REACH (Renewed Efforts Against Child Hunger) initiative, the first year of the implementation plan will start with building an enabling environment for improved nutrition outcomes using a coordinated multi-sectoral joint-up approach. This will entail review and updating of policies and strategies followed by their endorsement. The new NSDP should have a specific food and nutrition chapter, building on the draft already submitted to the Ministry of Planning for inclusion. Furthermore, efforts should immediately start to mainstream nutrition in all policies, frameworks and strategies. The Nutrition Division of the Ministry of Agriculture and Food Security (MoAFS) must prioritize development of a food and nutrition strategy to guide their actions and those of MoAFS. Precedence will be given to the finalisation of the Food and Nutrition strategy and costed action plan as well as its endorsement. Development of the food fortification legislation and the finalisation of the code of marketing for breastmilk substitutes will be given priority and will commence in the first year. This will include technical support and leveraging of financial support Lesotho Food and Nutrition Strategy and Action Plan Page 92 from the private sectors with interest in food fortification and breastmilk substitutes. Printing and dissemination of the finalised policies, guidelines and strategies will commence in the first year. Ensuring functional, efficient, effective and strategic leadership, management and coordination that adequately supports implementation of the nutrition multi sectoral plan is critical to its success. The creation of the Food and Nutrition Commission (FNC) under the Prime Minister’s Office will be prioritised in the first two years to ensure effective decentralization of nutrition actions and resources. Food and Nutrition Coordinating Office will provide overall technical leadership in the management of the commission at all levels including serving as the Secretariat to the FNC and serving as chair and secretariat to the multi sectoral platforms. The revitalisation of all coordination structures from central level to community level will be prioritised in the second year of the implementation. Currently, nutrition is not adequately prioritised in the allocation of financial resources and has a negative bearing on the efforts towards improved nutrition. Priority will be given to resource mobilisation for nutrition and promoting private public partners in the first and the second year of the implementation plan. A resource mobilisation advocacy plan will be developed during the first year to advocate for resource allocation for nutrition interventions by both Government and Partners. This will ensure adequate funding to support nutrition activities for improved nutrition outcomes. The integration of nutrition into harmonised sectoral plans, common results framework and M&E systems will be pursued. High priority will be accorded to strengthening the nutrition surveillance system and the early warning information system. Due to the paucity in the nutrition data and information at all levels precedence will be given to the development of the multi sectoral information system that will track program performance, implementation and financial resources and building an evidence base for decision making. This will generate data reflecting the multi- sectoral approach to nutrition, embracing the national, regional, district and community levels. A review and mapping of roles and responsibilities of different partners will commence in the first year and ensue in the second and year to maximise on different complementarities, avoid duplication and minimise conflict of interest that tend to misdirect scarce public and private resources. It is envisaged that building enabling environment at all structural and institutional levels across sectors will contribute to accelerated and sustained nutrition improvements. In the short term, efforts will be dedicated towards strengthening food and nutrition coordination and partnerships among nutrition stakeholders in order to improve the impact of nutrition activities implemented across the sectors. FNCO will hold and document regular joint planning and review meetings with stakeholders to align the annual nutrition planning process to the nutrition action plan. Mandates and responsibilities will be consolidated for all nutrition stakeholders at different levels to avoid duplication of efforts. Short-term trainings on management functions will also be offered to the coordinating body. Information Education Committee (IEC) should be resuscitated for the purpose of evaluating all nutrition information materials available, this will continue in to the medium-term. The on-going school feeding programme will continue. A study will be conducted about school feeding policy extension to inform further policy development and resource allocation. Additional short term interventions will include those to:  Create awareness on the importance of prevention; management and control of diet related NCDs.  Promote proper food handling, hygiene, and sanitation through increased knowledge, use of safe water, and hand washing practices at household level.  Promote male involvement in family health services and in food security and nutrition programmes. Lesotho Food and Nutrition Strategy and Action Plan Page 93  Advocate and seek solutions for reducing workload for all women, especially pregnant women and lactating mothers.  Recruit research teams to address critical gaps in food and nutrition status in the country.  Review, develop and implement nutritional guidelines for schools and other institutions. Medium-term strategic activities The government and partners will focus on raising additional resources in the country to scale-up evidenced-based high-impact interventions, and to strengthen nutrition coordination and partnership activities at all levels. Advocacy for promotion of nutrition and food security at district and sub-country levels will be intensified. Nutrition issues will be integrated into plans and budgets at all levels of governments by mainstreaming nutrition and creating specific vote functions for nutrition. Nutrition stakeholders will be assisted to develop and use clear structural national monitoring and evaluation tools that will help for effective planning and reporting. Formation of a national M&E team that is derived from the stakeholders and will use the tools developed to evaluate the work done across sectors and come up with necessary recommendations will be done. In addition feed-back mechanisms on nutrition information among nutrition stakeholders will be put established. The structure of the coordinating body shall be reviewed and upgraded. Strengthening of multi- sectoral coordination mechanisms and networks for nutrition at all levels will be prioritised as well. The Ministry of Education and Training will commission the review of school feeding policy. Additional medium-term actions envisaged include those to:  Review, develop and implement comprehensive guideline for prevention, management and control of diet related NCDs.  Research recruitment to address critical gaps in food and nutrition status in the country.  Mainstream basic nutrition training in all schools and other institutions.  Implement appropriate nutrition interventions in schools and other institutions.  Strengthen monitoring and evaluation of nutrition interventions in school and other institutions.  Create national food fortification programmes.  Develop IEC materials on healthy eating habits.  Finalize food safety standards bill.  Establish research coordination mechanism on consumer issues at national and country levels.  Capacity build food and nutrition advocacy planers and implementers.  Develop and enact marriage laws and enforce in order to eliminate child marriages, teenage pregnancies as well as reduce malnutrition.  Put in place consumer protection laws and regulations should be in place with regards to foods.  Mobilize nutrition stakeholders’ commitment towards sustaining institutional feeding programmes. Long-term strategic activities In the longer term, guidelines and tools on surveillance, monitoring and evaluation will be reviewed, further developed and disseminated widely. The functionality of the tools will be tested and altered if necessary. Lesotho Food and Nutrition Strategy and Action Plan Page 94 Laws will be enacted to promote provision of accurate nutrition information in order to reduce false information, and promote positive behaviours. The country will build upon achievements made with the school feeding policy that only caters for primary level; by developing other policies that cover other institutions such as public and private in order to contribute to the overall nutrition efforts e.g., conducting a situation analysis on school, institutional feeding and reviewing existing guidelines. The school feeding policy should be reviewed so that it can be extended to higher levels. Additional policies, laws and regulations will be put in place that support activities that promote food safety and prevent deterioration of nutritional status and save lives of vulnerable groups e.g., in outbreaks or severe illnesses. Other critical strategies in the long term shall be:  Creation of monitoring and evaluation systems for diet related NCDs will be supported.  Carry-out need-based research to inform policy program designs and implementation, including on consumer protection laws and regulations.  Strengthen the capacity of relevant research institutions to conduct nutrition research.  The strengthening of WASH policy through enforcement of laws regarding hygiene, washing of hands and provision of safe and clean water should be in place.  Review nutrition issues in the existing curricula of formal and non- formal education and in pre- and in- service training.  Strengthen nutrition policies and guidelines for tackling IYCF, HIV/AIDS, food fortification and micronutrient supplementation.  Review, develop and implement national micronutrient deficiency control strategy and guidelines.  Strengthen enforcement of food safety laws and regulations. 12 STRATEGIC RESULTS FRAMEWORK AND M&E PLAN The proposed results framework for the Lesotho Food and Nutrition Security Strategy and Costed Action Plan has three levels:  Impact level results.  Outcome level results;  Output level results. 12.1 Impact level results The description, indicators and baseline and target values for the impact level results are summarised in Table 22. Table 22: Impact level results Impact Description Impact Indicator Measurement Unit (e.g., %) Baseline Target Data Source Baseline Baseline Period 2023 Improved life expectancy Life expectancy Years Census Report 56 2016 60 Lesotho Food and Nutrition Strategy and Action Plan Page 95 Impact Description Impact Indicator Measurement Unit (e.g., %) Baseline Target Data Source Baseline Baseline Period 2023 Maternal mortality ratio Number of deaths / 100,000 live births LDHS 1024 2014 828 Under-five mortality rate Number of deaths per 1,000 live births LDHS 85 2014 Reduction in malnutrition Proportion of women 15-49 who are overweight or obese BMI >25 (overweight); BMI 30 and above (obese) LHDS 45 (42) (42) 2014 40 Proportion of children under-five who are overweight or obese Percent LHDS 7 (7) (7) 2014 7 Prevalence of wasting in children under the age of five years Percent LHDS 2.8 (4) (5) 2014 1.8 Prevalence of under- weight in children under the age of five years Percent LHDS 10.3 (13) (16) 2014 7 Prevalence of stunting in children under the age of five years Percent LHDS 33.2 (39.2) (44) 2014 18 Proportion of acute, moderate and severe malnutrition Percent LHDS tbc 2014 tbc Prevalence of NCDs (breast cancer, cervical cancer, diabetes, blood pressure) among 15- 49 year old women Percent LDHS tbc 2014 tbc Proportion of under- five children with Vitamin A deficiency LDHS 32.7 2014 28 Proportion of children age 6-59 months anaemic LDHS 50.8 2014 45 Prevalence of iron- deficiency anaemia in women aged 15- 49 years Percent LDHS 27.3 2014 20 Proportion of women 15-49 years anaemic LDHS 27 2014 20 Proportion of men 15-49 anaemic LDHS 14 2014 10 Reduction in waterborne diseases Proportion of children under age 5 that had diarrhoea in the 2 weeks preceding the survey Percent LDHS 12 2014 8 12.2 Outcome level results Outcome level results are presented in Table 23. It shows the anticipated outcomes, key indicators for tracking these outcomes and baseline and target values. The source of the data is also indicated. Lesotho Food and Nutrition Strategy and Action Plan Page 96 Table 23: Outcome level results Outcome Description Impact Indicator Measureme nt Unit (e.g. %) Baseline Target Data Source Baseline Baseline Period 2023 Outcome Area 1: IYCF Improved Infant and Child Feeding Practices Proportion of children under 6 months exclusively breastfed Percent LDHS 67 2014 80 Proportion of infants who breastfed within 1 hour of birth Percent LDHS 65 2014 80 Proportion of children 6- 23 months who continued breastfeeding up to 24 months Percent LDHS 30 2014 60 Proportion of children age 6–23 months who receive a minimum acceptable diet (apart from breast milk) Percent LDHS 11.3 2014 17 Outcome Area 2: Micronutrient Supplementation and Fortification Prevalence of iron- deficiency anaemia in children aged 6-59 months Percent LDHS 50.8 2014 45 Prevalence of iron- deficiency anaemia in women aged 15-49 years Percent LDHS 27.3 2014 20 Proportion of children 6- 59 months consuming foods rich in iron Percent LDHS 60.5 2014 75 Proportion of children 6- 59 months consuming foods rich in Vitamin A Percent LDHS tbc 2014 tbc Outcome Area 3: Maternal health and nutrition Proportion of women who received post-natal care within 2 days after delivery Percent LDHS 62 2014 68 Proportion of women who gave birth 5 years before the survey and received ANC from a skilled health provider in their most recent birth who received in their first trimester Percent LDHS 41 (33) (30) 2014 50 Proportion of women who gave birth 5 years before the survey and received ANC from a skilled health provider in their most recent birth Percent LDHS 95 (92) (90) 2014 97 Proportion of women who gave birth 5 years before the survey and received ANC from a skilled health provider in their most recent birth who have received the recommended ANC visits Percent LDHS 74 () () 2014 85 Contracepti ve use Contraceptive prevalence rate among Percent LHDS 60 (46) (35) 2014 75 Lesotho Food and Nutrition Strategy and Action Plan Page 97 Outcome Description Impact Indicator Measureme nt Unit (e.g. %) Baseline Target Data Source Baseline Baseline Period 2023 improved married women aged 15- 49 years (percentage who use any contraceptive method) Coverage of child immunisatio n increased Proportion of children (12-23 months) who are up to date in their immunisation target (received all basic vaccinations) Percent LDHS 68 (62) (68) 2014 75 Child marriages reduced Proportion of teen females married before the age of 18 years Percent LHDS 25 2014 20 Proportion of women who were married before age 18 Percent LDHS 25 () (35) 2014 20 Adoption of healthy lifestyles increased among adult population HIV prevalence among women 15-49 years Percent LDHS 30(27)(26) 2014 27 Outcome Area 4: Strengtheni ng Clinical Services Quality of nutrition services improved Proportion of health facilities adopting food service and nutrition guidelines Percent tbc tbc tbc tbc Proportion of health facilities providing quality nutrition services Percent tbc tbc tbc tbc Adoption of healthy lifestyles increased among adult population Proportion of adult population practicing at least two or a combination of the top 5 healthy lifestyles Percent tbc tbc tbc tbc Outcome Area 5: Food Value Chain Reduce the proportion of the population food insecure Proportion of the country's population that is food insecure Percent LVAC 25 2017 12.5 Number of the country's population that is food insecure Percent LVAC 224664 2017 112332 Population living under the national poverty line Percent Census 57.1 2016 45 Number of disease outbreaks linked to food safety tbc tbc tbc tbc Proportion of households with a moderate to high dietary diversity score (minimum is 8% and moderate 27% and 66% low) Percent LVAC 66% low 27% moderate 8% high 2017 40 low 40 moderate 20 high Post-harvest loss rate for staple cereal crops Percent LVAC tbc 2017 tbc Number of cattle deaths annually due to Anthrax Number MoAFS tbc tbc tbc National cereal food Tonnes LVAC /BOS tbc 2017 tbc Lesotho Food and Nutrition Strategy and Action Plan Page 98 Outcome Description Impact Indicator Measureme nt Unit (e.g. %) Baseline Target Data Source Baseline Baseline Period 2023 deficit Proportion of farmers using organic farming methods Percent MoAFS tbc tbc tbc Outcome Area 6: WASH Increase access to, and use of improved water, sanitation and hygiene facilities Access to improved source of drinking water Percent LDHS 54 () () 2014 65 Access to improved sanitation facilities Percent LDHS 47.1 () () 2014 55 Proportion of households with the ideal handwashing practices (presence of soap and water at usual handwashing location) Percent LDHS 46 2014 70 Improve treatment of diarrhoea Proportion of children under age 5 that had diarrhoea in the 2 weeks preceding the survey who received ORS Percent LDHS 75 2014 85 Proportion of children under age 5 that had diarrhoea in the 2 weeks preceding the survey who went untreated Percent LDHS 75 2014 65 Outcome Area 7: Social Protection Proportion of women in Lesotho who reported at least one of the four problems asked about in accessing health care for themselves (e.g., getting permission to go to the doctor; getting money for advice or treatment; distance to a health facility; not wanting to go alone) Percent LDHS 42 2014 35 Proportion of households receiving social assistance who have a moderate to high dietary diversity score (minimum is 8% and moderate 27% and 66% low) Percent LVAC* tbc 2018 tbc Proportion of mothers of children 0-6 months receiving infant grant who are practicing exclusive breastfeeding Percent LDHS* tbc 2019 tbc Outcome Area 9: Gender equality and Women's Empowerment Proportion of mothers or caregivers of children aged 0-23 months whose spouses are involved in optimal child feeding Percent tbc tbc tbc tbc Proportion of mothers or caregivers of children aged 0-23 months whose spouses are involved in optimal child hygiene Percent tbc tbc tbc tbc Proportion of mothers or caregivers of children aged 0-23 months whose Percent tbc tbc tbc tbc Lesotho Food and Nutrition Strategy and Action Plan Page 99 Outcome Description Impact Indicator Measureme nt Unit (e.g. %) Baseline Target Data Source Baseline Baseline Period 2023 spouses are involved in optimal child feeding, hygiene and health care Proportion of women who participate in decisions on own health care, major household purchases, and visit to family or relatives Percent LDHS 65 2014 80 Outcome Area 10: Capacity Building Capacity for coordinatio n of multi- sectoral approach to nutrition strengthene d Number of sectors with nutrition integrated into the sector plans and being implemented Number FNCO Agri Health Education Trade, social Developme nt, 15 Number of sector policies revised to mainstream nutrition Number tbc tbc tbc tbc Number of legal frameworks (laws, regulations, codes, guidelines produced and approved) Number tbc tbc tbc tbc Number of nutritionists reached with inservice training (total and per sector) Number FNCO Annual Training Report 0 2017 15 Operational status of the Lesotho Food and Nutrition Society Status stages FNCO Annual Report Not operational 2018 Operational Nutrition coordination meetings with reports on progress made in implementation resolutions made Number SUN Global Reporting Annual Self-Assessment tbc 2017 tbc Number of SUN Networks established and fully operational Number Annual SUN Self- Assessment Report tbc 2017 tbc Number of SUN Focal Point Quarterly Meetings held per year Number Annual SUN Self- Assessment Report tbc 2017 tbc Outcome Area 11: Enabling Environment Resource mobilisation and evidence generation strengthene d Proportion of national budget allocated to nutrition Percent SUN Annual Financial Tracking Report; Clinton Health Access Initiative (CHAI) Annual Report 3 (TBC) 2017 3 Status of food and nutrition information Status FNCO Annual Report No nutrition surveillance 2017 Surveillance data available and informs decisions Number of national nutrition studies conducted Number FNCO Annual Report 0 2017 Monitoring of the implementation of the NNS recommendation s 12.3 Output level results Lesotho Food and Nutrition Strategy and Action Plan Page 100 The annual output targets to be achieved by stakeholders implementing various activities envisaged under the Food and Nutrition Security Strategy and Costed Action Plan are presented in Annex 3. Lesotho Food and Nutrition Strategy and Action Plan Page 101 13 RESOURCE REQUIREMENTS 13.1 Resource Requirements Using marginal costing principle, and a combination of zero-based and historical costing approaches, the estimated total financial requirements of the strategy over five years came to US$239 million (Table 23). Most of the costs (64%) are for activities that are proactive and prevent malnutrition from occurring. Every opportunity available to mainstream nutrition education and awareness promotion into existing and planned short-term emergency and long- term development interventions is taken advantage of so that nutrition messaging rides on other initiatives and the additional cost of promoting nutrition security is kept as low as possible. The importance of the multi-sectoral approach is observed as supporting the improvement of interventions in the food value-chain, social protection, water, hygiene and sanitation is recognised through the estimated shares of the total budget, namely 4%, 2%, and 7%, respectively. Proactively promoting nutrition in emergencies features prominently in the resource requirements as 30% of the budget is envisaged for activities that prevent deterioration of nutritional status of poor and vulnerable populations. Initiatives to prevent stunting by exploiting potential interventions that have been proven to work in the window of opportunity presented by the first 1,000 days of a child’s life carry significant weight in the budget, as 11% of the resource requirements will support infant and young child nutrition interventions, especially promotion of early initiation of breastfeeding within the first hour of birth, as well as exclusive breastfeeding, adequate complementary feeding and continuing breastfeeding. Maternal and child health and nutrition interventions are equally critical and constitute 19% of the cost estimate. Promoting gender equality and women’s empowerment has been estimated at 1% of the resource requirements. 13.2 Financing Plan The Government of Lesotho is expected to mobilise and allocate a substantial part of the resources through the national budget. Development partners can complement these efforts. The UN agencies, NGOs and the private sector will also make important contributions to financing of activities in the strategic plan. To support the Government in its efforts to mobilise resources, a National Nutrition Fund is proposed, with a relevant legal instrument to support its setting up and functionality. Following the launch of the National Food and Nutrition Security Strategy by the Government it is expected that a National Nutrition Investment Forum will be convened by His Majesty the King and development partners will pledge their support. Development partners can use current initiatives they are sponsoring in various sectors to fine-tune and creatively resource nutrition or to commit new funding to key strategies articulated in this food and nutrition security strategy. Lesotho Food and Nutrition Strategy and Action Plan Page 102 Table 24: Budget Breakdown by Key Result Area and Goal Key Result Areas and Goals Estimated Cost per Year, USD Total Cost, USD Percent 2019 2020 2021 2022 2023 Goal KRA Key Result Area 1: Infant and Young Child Feeding (USD) 4,796,161 5,037,034 5,288,885 5,553,329 5,830,996 26,507,420 11% Goal 1: To increase the proportion of children 0-6 months exclusively breastfed from 67% to 80% by 2023 771,550 811,192 851,751 894,339 939,056 4,268,902 2% Goal 2: To increase the proportion of children 6-23 months that are receiving adequate and appropriate complementary feeding and continuing breastfeeding from 11.3% to 20% by 2023 682,452 716,575 752,403 790,023 829,525 3,770,978 2% Goal 3: To increase the proportion of new-born children that receive early initiation of breastfeeding (within the first hours of birth) from 65% to 80% 3,342,159 3,509,267 3,684,731 3,868,967 4,062,415 18,467,539 8% Key Result Area 2: Micronutrient Supplementation (USD) 8,997,762 8,782,736 8,742,306 731,994 8,742,194 45,225,472 19% Goal 1: To reduce anaemia prevalence in children (6-59 months) from 50.8% to 20% 8,138,018 8,082,736 8,042,306 31,994 8,042,194 40,278,158 17% Goal 2: To increase vitamin A coverage for children 6-59 months from 32.7% to 60% by 2023 643,344 620,000 620,000 620,000 620,000 4,339,324 2% Goal 3: To increase the proportion of children 6-23 months consuming foods rich in vitamin A from 60.5% to 85% by 2023 80,000 80,000 80,000 80,000 80,000 400,000 0% Goal 4: To increase the proportion of households with iodised salt from 92.9% to 100% in 2023 136,400 - - - - 207,990 0% Key Result Area 3: Maternal and Child Health (USD) 9,082,158 7,447,394 8,376,542 8,425,576 8,396,569 41,728,240 17% Goal 1: To increase the proportion of women who receive post-natal care within 2 days after delivery from 62% to at least 80% and those receiving nutrition education on the 7th day after delivery to at least 50% by 2023 3,390,576 2,894,862 3,490,576 3,490,576 3,490,576 16,757,165 7% Goal 2: To increase vaccination coverage to two-thirds (form one third) and deworming coverage from 22% to 90% for children under 5 years by 2023 1,271,208 1,187,473 1,116,045 1,131,366 1,116,045 5,822,138 2% Goal 3: To increase the coverage of growth monitoring and promotion for under- fives at community level to 95% by 2023 2,309,979 2,309,951 2,309,951 2,329,979 2,309,951 11,569,811 5% Goal 4: To increase the proportion of expectant mothers with first ANC visit within the first trimester from 41% to 60% by 2023. 971,564 1,041,421 1,041,421 1,041,421 1,041,421 5,137,250 2% Goal 5: To develop adolescent nutrition service guidelines and ensure at least 30% coverage of adolescent nutrition services by 2023 1,138,831 13,686 418,549 432,234 438,576 2,441,876 1% Key Result Area 4: Food Value Chain (USD) 371,628 2,402,128 3,629,585 2,154,822 654,822 9,212,986 4% Goal 1: To reduce the proportion of the population that is food insecure by 50% (from 22.74% to 11.37%) by 2023 256,660 2,214,511 2,277,168 1,972,858 572,858 7,294,054 3% Goal 2: To increase the proportion of the population (with special focus on children 6-23 months, adolescent girls, women of child bearing age) consuming foods rich in iron, zinc, calcium, vitamin A and others by 30% by 2023 - 109,050 3,850 103,850 3,850 220,600 0% Goal 3: To reduce the population living under the national poverty line from 57.1% to 45% by 2023 66,800 66,800 66,800 66,800 66,800 334,000 0% Goal 4: To ensure all food is safe for human and animal consumption 48,168 11,768 1,281,768 11,314 11,314 1,364,332 1% Key Result Area 5: WASH (USD) 3,366,685 3,299,542 3,293,828 3,293,828 3,293,828 16,547,711 7% Goal 1: To increase the proportion of the population provided with access to an improved source of drinking water to 90% in rural and 100% in urban areas, and ensure all households without access treat the water by 2023 681,345 681,345 681,345 681,345 681,345 3,406,726 1% Goal 2: To increase the proportion of population with access to an improved sanitation facility from 47.1% to 60% and those using a sanitation facility from 73% to 85% by 2023 399,909 332,766 327,051 327,051 327,051 1,713,829 1% Goal 3: To increase the proportion of households with the ideal handwashing practices (water and soap) from 46% to 70% by 2023 2,285,431 2,285,431 2,285,431 2,285,431 2,285,431 11,427,157 5% Key Result Area 6: Social Protection (USD) 18,521 78,542 60,510 1,123,496 2,448,561 3,729,631 2% Goal 1: To increase the proportion of pregnant and nursing mothers and children who have access to health and nutrition services to 80% by 2023 - 1,232 26,014 1,050,000 2,400,000 3,477,246 1% Goal 2: To increase knowledge and appreciation of the importance of nutrition to child growth and development - - - 23,000 16,000 39,000 0% Goal 3: To improve the intake of nutritious foods among the recipients of social assistance - 16,000 14,374 31,974 14,040 76,389 0% Goal 4: To expand coverage by National Information System for Social 3,893 3,893 5,493 3,893 3,893 0% Lesotho Food and Nutrition Strategy and Action Plan Page 103 Key Result Areas and Goals Estimated Cost per Year, USD Total Cost, USD Percent 2019 2020 2021 2022 2023 Goal KRA Assistance (NISSA) by 124% from 170,000 households in 2017/18 to 380,000 households by end of 2020/21 and assist those in need of good nutrition 21,064 Goal 5: Promote breastfeeding among infant grant recipients 14,629 57,417 14,629 14,629 14,629 115,931 0% Key Result Area 7: Capacity building (USD) 327,962 285,714 285,714 497,143 497,143 1,893,676 1% Goal 1: To fully establish, strengthen and empower the multi-sectoral food and nutrition coordinating institutional framework at national, district and community levels by 2023 327,962 285,714 285,714 497,143 497,143 1,893,676 1% Key Result Area 8: Enabling Environment (USD) 948,891 791,451 261,527 152,424 130,284 2,284,575 1% Goal 1: To increase resource allocation to nutrition to 3% of national budget and mobilise funding from development partners by 2023, to meet the scaling-up of nutrition commitment made by the country in 2014 142,340 120,200 61,160 83,300 61,160 468,160 0% Goal 2: To develop new, review existing, and fully enforce food and nutrition legal frameworks (such as food fortification law, code of marketing of breastmilk substitutes, monitoring of salt iodisation, maternity protection, establishment of FNCO commission/authority, food safety law), guidelines and standards by 2020. 347,778 224,778 87,018 3,378 3,378 666,330 0% Goal 3: To fully integrate nutrition into existing and new national and sectoral policies, strategies, plans and curricula by 2023 303,604 303,604 2,460 2,460 2,460 614,588 0% Goal 4: To develop and implement a new nutrition information system for nutrition by December 2019 155,169 142,869 110,889 63,286 63,286 535,497 0% Key Result Area 9: Gender Equality and Women’s Empowerment (USD) 254,008 263,388 264,700 264,700 164,700 1,211,496 1% Goal 1: To increase the proportion of mothers and care givers of children 0-23 months whose spouses are involved in optimal child feeding, hygiene and health care to 80% by 2023 108,608 34,188 35,500 35,500 35,500 249,296 0% Goal 2: To increase the coverage of women of child bearing age and caregivers of under-fives with access to appropriate labour saving technologies for food production, processing, preservation and preparation as well as water supply and purification to 40% by 2023 20,400 104,200 104,200 104,200 4,200 337,200 0% Goal 3: To increase the proportion of women who participate in decisions on own health care, major household purchases and visit to family or relatives from 65% to 80% by 2023 125,000 125,000 125,000 125,000 125,000 625,000 0% Key Result Area 10: Strengthening clinical services (USD) 3,755,515 4,115,515 4,325,267 3,456,500 3,410,500 19,063,297 8% Goal 1: To increase the proportion of adult population practicing at least two or a combination of the top 5 healthy lifestyles by 50% by 2023 210,000 376,000 769,752 210,000 210,000 1,775,752 1% Goal 2: Increase the proportion of health facilities providing quality nutrition services to 75% by 2023 2,945,515 3,119,515 2,945,515 2,636,500 2,590,500 14,237,545 6% Goal 3: Proportion of health facilities adopting food service and nutrition guidelines by 2023 20,000 40,000 30,000 30,000 30,000 150,000 0% Goal 4: Prevention and management of nutrition-related non-communicable diseases (NCDS) 580,000 580,000 580,000 580,000 580,000 2,900,000 1% Key Result Area 11: Nutrition in emergencies (USD) 14,215,409 15,160,896 14,241,600 14,409,382 14,271,672 71,885,442 30% Goal 1: To ensure timely access to adequately nutritious food for people affected by emergencies 7,391,514 7,391,514 7,391,514 7,391,514 7,391,514 36,957,570 15% Goal 2: Improve environmental Health and Access to Nutrition and Health Services for people affected by emergencies 6,108,528 7,035,158 6,115,862 6,283,644 6,145,934 31,275,607 13% Goal 3: Prevent deterioration of nutritional status and save lives of vulnerable groups/prevent mortality 715,367 734,224 734,224 734,224 734,224 3,652,265 2% TOTAL 46,134,700 47,664,340 48,770,465 40,063,194 47,841,270 239,289,945 100% Lesotho Food and Nutrition Strategy and Action Plan Page 104 A conference with civil society partners will be held to explore ways in which they can support the implementation of the food and nutrition security strategy. They will be requested to make commitments that will help the government in filling some gaps in interventions either by way of supplementing the technical capacity of government or reaching areas that are unreached by the state. A nutrition-for-growth (N4G) initiative will be launched in Lesotho to garner private sector funding for nutrition. Private sector companies in the food value-chain will be briefed on the investment priorities and opportunities in the strategic plan and provided space to support the national efforts through solid commitments on how they will increase their investment in strategies that complement those of government in addressing nutrition challenges facing the country. A crowd-sourcing mechanism will be established to innovatively fund nutrition and appropriate policy and legislation will be put in place to support it. Finally a nutrition financing tracking mechanism will be designed and operationalised to ensure that investments being made in nutrition are monitored and reported on. The Office of the Prime Minister through FNCO will provide overall direction in resource mobilisation. Lesotho Food and Nutrition Strategy and Action Plan Page 105 14 ANNEX 1: GLOSSARY OF TERMS Term Definition Acute malnutrition (wasting) Low weight-for-height defined as more than 2 standard deviations (SD) below the mean of the sex-specific reference data. Wasting is usually the result of a recent shock such as lack of calories and nutrients and/or illness, and is strongly linked to mortality. Adequately iodized salt Salt containing l5-40 parts per million of iodine. At the population level, household access to iodized salt should be greater than 90 percent, constituting universal salt iodization. Anaemia The condition of having a haemoglobin concentration below a specified cut-off point, which can change according to age, gender, physiological status, smoking habits, and altitude at which the population being assessed lives. The World Health Organization (WHO) defines anaemia in children under five years of age and pregnant women as a haemoglobin concentration <110g/1 at sea level. Although the primary cause of anaemia worldwide is iron deficiency, it often coexists with a number of other anaemia causes, including malaria and other parasitic infections; acute and chronic infections that result in inflammation and haemorrhages; deficiencies in other vitamins and minerals, especially folate, vitamin B and vitamin A; and genetically inherited traits, such as thalassemia. Bio-fortification The development of micronutrient-dense staple crop varieties using traditional breeding practices or biotechnology. Breast-milk substitute Any food marketed or otherwise represented as a partial or total replacement for breast-milk, whether or not suitable for that purpose. Chronic malnutrition (stunting) Low height-for-age, defined as more than 2 SD below the mean of the sex-specific reference data. Stunting is the cumulative effect of long-term deficits in food intake, poor caring practices, and illness. Colostrum The first fluid secreted by the breast during late pregnancy and the first few days after birth. Complementary feeding practices A set of 10 practices recommended for caregivers to implement from 6 to 24 months, at which point breast milk and/or breast milk substitutes alone are no longer sufficient to meet the nutritional needs of growing infants. Poor breastfeeding and complementary feeding practices, coupled with high rates of infectious disease, are the principal proximate causes of malnutrition during the first two years of life. Dietary diversity The number of food groups consumed over a given period of time. Household level dietary diversity can be used as an indicator of household food security, and individual-level dietary diversity is an indicator of diet quality for an individual (typically measured for women or young children). Early initiation of breastfeeding Initiation of breastfeeding within one hour of birth. As a public health statistic, it is measured as the proportion of children born in the past 24 months who were put to the breast within one hour of birth. Exclusive breastfeeding The feeding of an infant only with breastmilk from his/her mother or a wet nurse, or expressed breastmilk, and no other liquids or solids except vitamins, mineral supplements, or medicines in drop or syrup form. Food fortification The addition of one or more micronutrients (vitamins and minerals) to a food during processing. Ideally, food fortification Lesotho Food and Nutrition Strategy and Action Plan Page 106 Term Definition provides a public health benefit with minimal risks to health in the population. Food security According to the UN, food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritional food to meet their dietary needs and food preferences for an active and healthy life. The concept of food security includes the pillars of food availability, access, utilization, and stability/vulnerability. Gender A concept that refers to the social differences between women and men that have been learned are changeable over time and have wide variations both within and between cultures (European Commission, 1998). Gender disaggregated data Specification of data for women/girls as compared to men/boys. Breaking down (or disaggregating) social economic statistics to show the differences and similarities between (different groups of) women/girls and men/boys. These data are fundamental for accountability as they allow to assess the impact of policies, plans, programmes, projects and budgets on gender relations. Gender mainstreaming The process of incorporating a gender equality perspective in all policies ,strategies and interventions ,at all levels and at all stages Mainstreaming a gender perspective is the process of assessing the implications for women and men of any planned action ,including legislation ,policies or programmes ,in an area at all levels .It is a strategy for making the concerns and experiences of women as well as of men an integral part of the design, implementation ,monitoring and evaluation of policies and programmes in all political ,economic and societal spheres ,so that women and men benefit equally ,and inequity is not perpetuated .The ultimate goal of mainstreaming is to achieve gender equality. Gender equality The concept meaning that all human beings are free to develop their personal abilities and make choices without the limitation set by strict gender roles ;that the different behavior ,aspirations and needs of women and men are considered ,valued and favored equally (European Commission ,1998). This is achieved when the different behavior aspirations and needs of women and men are equally valued and favored and do not give rise to different consequences that reinforces inequalities (EC 2006). Gender inequality Unequal access to and control over the various material and non-material resources and assets of the society .In all societies the women’s role is the inferior one in the relationship .There is still no country in the world where women have equal access to power and decision –making ,and to decent and well-paid jobs. Gender needs Specific needs of men and women which result from their socially constructed and assigned roles in their family, their community and their historical and social context. Two types of needs are usually identified: Practical gender needs arise from the actual living conditions of women and men, which can be improved without changing the gender roles assigned to them in society. Strategic gender needs are the needs to change the traditional gender roles based on subordination of women to men and to promote gender equality. Gender relations Socially created relations between men and women which can vary widely among cultures and change over time. Gender roles A set of prescriptions for action and behavior allocated to women and men respectively within a given social historical context. Gender roles are ‘socially constructed’, which means that they Lesotho Food and Nutrition Strategy and Action Plan Page 107 Term Definition are shaped by multiplicity of social, economic, political, cultural and other factors and will change with changes in these formative influences. Gender sensitive Addressing and taking into account the gender dimension. (European Commission, 1998). Gender sensitive indicators Indicators that give due consideration to the different roles and responsibilities of men and women in all their diversity. Gender sensitive indicators are key tools for gender mainstreaming. Global acute malnutrition (GAM) Global acute malnutrition is weight-for-height of -2 z-scores or more below the median, according to the WHO's child growth standards (moderate and severe wasting). Infant and young child feeding Refers to specific recommendations and guiding principles for optimal nutrition, health, and development of children. A set of eight population-level IYCF indicators have been developed to: (i) assess IYCF trends over time; (ii) improve targeting of interventions; and (iii) monitor progress in achieving goals and evaluate the impact of interventions (WHO, 2008). Maternal mortality The number of women who die during pregnancy and childbirth, per 100,000 live births. (Data available at UNICEF and WHO). Micronutrients Vitamins and minerals that are needed in small amounts by the body to produce enzymes, hormones, and other substances essential for proper growth and development. Iodine, vitamin A, iron, and zinc are the most important in terms of prevalence and severity; deficiencies are a major threat to the health and development of populations worldwide, particularly children and pregnant women in low-income countries. Moderate acute malnutrition Weight-for-height between -2 and -3 standard deviations below the mean of sex-specific reference data (moderate wasting). Moderate malnutrition Weight-for-age between -2 and -3 z-scores below the mean of sex-specific reference data (moderate underweight). Nutrition security The ongoing access to the basic elements of good nutrition, i.e., a balanced diet, safe environment, clean water, and adequate health care (preventive and curative) for all people, and the knowledge needed to care for and ensure a healthy and active life for all household members. Poverty Poverty is understood not just as a lack of income and financial resources but also encompasses the notion of inequalities in access to and control over other material and non-material benefits of a society. An important determinant of inequality in access to these benefits is gender. (Jane Haile, 2008) Practical gender needs Needs related to women’s and men’s traditional gender roles and responsibilities and derived from their concrete life experiences. For example, when asked what they need, women usually focus on immediate practical needs for food, water, shelter, health and so on. Reproductive Rights The right of any individual or couple to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. Sex disaggregated statistics The collection and separation of data and statistical information by set to enable comparative analysis sometimes referred to as gender disaggregated statistics. (European Commission, 11998). Stakeholder Those who are interested and/or involved in a specific activity or initiate. They are not necessary involved directly in the project work. Stereotypes Are shared beliefs that a group of people hold about another category or group of people or individuals. Gender stereotypes refer to shared beliefs about members of the categories men or Lesotho Food and Nutrition Strategy and Action Plan Page 108 Term Definition women. Strategies Strategies integrate major policies and goals in a cohesive way and are needed for an effective, efficient and feasible allocation of resources. Wasting (acute malnutrition) Low weight-for-height defined as more than 2 SD below the mean of the sex-specific reference data. Wasting is the result of a recent shock such as lack of calories and nutrients and/or illness, and is linked strongly to mortality. Women’s triple role Women’s triple role refers to the reproductive, productive and community managing role. The way these forms are valued affects the way women and men set priorities in planning programs or projects. The taking or not taking into consideration of these forms can make or break women’s chances of taking advantage of development opportunities. (Moser, C.O., 1993). See: Triple role. 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