Somalia Multisectoral Nutrition Strategy 2019-2024

FEDERAL REPUBLIC OF SOMALIA SOMALIA MULTISECTORAL NUTRITION STRATEGY 2019-2024 March 2019 ii FORWARD Somalia is a signatory to several nutrition related global agreements and mechanisms including the Scaling Up Nutrition (SUN) Movement, the World Health Assembly (WHA) 2025 nutrition targets, the Sustainable Development Goals (SDGs), the United Nations (UN) Decade of Action on Nutrition (2016–2025), and the ICN2 Declaration and Plan of Action. The agreements lay down the foundation for addressing the immediate, underlying and basic causes of malnutrition including expanding the political, economic, social and technological space for nutrition actions. The vulnerability, food and nutrition insecurity in the country is indirectly linked to the livelihood and community structure which permeates the country’s wider economic and political structures. Variation in nutrition status across communities could be linked to livelihoods of Somalia population these are pastoralist, agro- pastoralist , coast and riverine, and urban livelihood. There is also a large population of internally displaced populations (IDPs) who experience lows social economic status that negatively affect their nutrition status. The backdrop in the attempt to plan for longer-term development in Somalia was defined by fragility of the State and a multidimensional conflict that negatively impacted on the fight against extreme poverty, food insecurity and contributed to poor nutrition outcomes. The decades of fragility and conflict led to the collapse of the formal health sector and the emergence of various fragmented and parallel health systems and infrastructures that have been unable to overcome the significant barriers to accessing quality nutrition care and support for most of the population, particularly for the most vulnerable subgroups in the population. Despite these challenges, Somalia continues to experience increasingly strong political, economic and institutional growth. A peaceful election and transition of power to Federal President Mohamed Abdullahi Mohamed and the formation of a new cabinet under the Prime Minister in 2017, are important political milestones. A range of policies and strategies have also been developed in relevant sectors. To this effect, the government through the office of the prime minister has clealy spelt out strategic steps and actions necessary to jump start the Somalian economy towards the path of economic developmet, in regard 4 strategic roadmaps have been developed to giude investment in four priority areas which are: Security and Justice; Inclusive politics; economic; and social development. Roadmap defines the main goals to be delivered and milestones to be accomplished by the responsible institutions (Ministries, independent institutions and various directorates) in order to delivering as per the government priorities. The Somalia multisectoral nutrition Strategy is anchored under the government priority areas and roadmap on social development, and builds on various existing policies relating to nutrition specific and nutrition sensitive policies in the country. The goal of MSNS is to reduce malnutrition direct through nutrition specific interventions and indirectly through nutrition-sensitive interventions that reduce poverty and food insecurity. The iii SMNS objectives and expected results are developed to encompass outcomes and activities that are considered effective for improvement of nutrition outcomes considering the evidence base. These specific objectives are vital to speeding up progress towards the improvement of the nutrition status of Somalia’s population, accelerate the achievement of the goals outlined in the government priority under the social development roadmap. H. E. HASSAN ALI KHEYRE PRIME MINISTER OF THE FEDERAL REPUBLIC OF SOMALIA iv PREFACE Nutrition is a major problem in Somalia, with prevalence of acute malnutrition consistently above World Health Organization (WHO) emergency thresholds, high levels of micronutrient deficiencies and extremely poor infant and young child feeding practices. This situation contributes substantially to high morbidity, mortality and overall disease burden in the country. The persistence of under nutrition also places a large burden on the struggling health care system directly or through contributing to the burden of disease and seriously impedes the realisation of Somalia’s economic and human development potential. The Government of Somalia has developed this Multisectoral Nutrition (MSN) Strategy to facilitate further cooperation across sectors towards improving nutrition outcomes for the Somali Population. The Strategy has been developed to buttress existing policy initiatives and build a stronger and coherent basis for a future with stronger prospects towards achievement of the government aspiration as outlined in the priority area and roadmap on economic and social development Finally, it important to note that the development of this Plan has involved a strong collaboration among key stakeholders of a wide range who have given valuable inputs towards identifying the priorities that need to be implemented during the next five years (2019-2024). Expectation therefore, is that in working together, the overall specific objectives of the MSN will be achieved. AHMED NUR (PhD) PRINCIPLE SECRETARY OFFICE OF THE PRIME MINISTER OF THE FEDERAL REPUBLIC OF SOMALIA. v ACKNOWLEDGEMENTS This Strategy and implementation plan were developed by SUN Secretariat at the Office of the Prime Minister and various line ministries of the Federal and State Governments of Somalia, donors and implementing partners. We express our sincere gratitude and indebtedness to the DFID of UK and the German Cooperation for supporting critical components of the work. Our special recognition goes to the DFID-funded Maximising the Quality of Scaling Up Nutrition Plus (MQSUN+) project and the consulting team led by Maina H. Muthee and comprising Tamsin Walters, Christopher Coffey, Job Gichuki, Rebekah Pinto and Ahmed Siyad and Dr. Daniel Mwai. This Common Results Framework and Multisectoral Nutrition Strategy would not have been completed without your invaluable expertise. Special appreciation goes to Dr. Farah, the SUN coordinator at the Office of the Prime Minister and to the dedicated staff at various line ministries who provided guidance and validation of various components of the Common Results Framework and Multisectoral Strategy. We are equally indebted to Dr. Mohamed A. Hassan in the Office of the Prime Minister for providing general oversight and support through the process. We also extend our gratitude to the line ministries at the State level who provided insights and support provided key insights during the development process and for ensuring that objectives are consistent with those of the government of Somalia. My thanks also go to the following organisations who gave their inputs in various fora: UNICEF, WFP, WHO, UNFPA, GIZ, FAO, BRiCS consortium, Nutrition cluster DR MOHAMED ABDI FARAH NATIONAL CORDINATOR FOR SCALING UP NUTRITION (SUN-FP) OFFICE OF THE PRIME MINISTER OF THE FEDERAL REPUBLIC OF SOMALIA vi EXECUTIVE SUMMARYAKU Aga Khan University The Multisectoral Nutrition (MSN) strategy 2019-2024 sets out to consolidate and integrate various policy instruments of the Somalia government that seek to tackle under nutrition. It extends beyond the health sector to include policies in other sectors seeking to ensure the current or future alignment of all government policies tackling under nutrition while at the same time eliminating fragmentation of policies. It is the second nutrition strategy that seeks to complement the existing policy objectives of the Somalia government. The strategic objectives and expected results have been developed in response to the set of challenges faced in Somalia and encompass outcomes and activities that are considered most likely to lead to improved nutrition outcomes considering the evidence base. The Strategy goes beyond preventive and curative nutrition interventions and encompasses actions from sectors ‘outside’ the Maternal Child Health (MCH) agenda to those that can provide a basis for accelerating progress or act as entry points for nutrition interventions (nutrition-sensitive sectors). The goal of MSN strategy is to reduce malnutrition through direct MCHN interventions and indirectly through nutrition-sensitive interventions that reduce poverty and food insecurity. The expected outcome is by the end of the multisectoral nutrition programme cycle, nutrition-specific and nutrition-sensitive interventions will effectively contribute to improved nutrition outcomes especially in the first 1,000 days of life and in early childhood up to 5 years of age. It is expected that the proportion of under five children who are stunted will decrease from the estimated 12 percent to seven percent consistently with the aspirations in the current National Development Plan (NDP); while those wasting will decrease to below WHO emergency levels; and more than half of the under-five cohort will be consuming the minimum acceptable diet. Furthermore, it sets forth an ambitious agenda for the initiation, scale up, alignment and harmonization of future policy and action. The Strategy also spells out the programme principles that the government and stakeholders should employ in pursuit of included results. The main audience for the MSN will be policy makers, planners, nutrition managers and officers at all levels, academia, development partners, donors, NGOs, Civil Society Organizations (CSOs), Faith-Based Organizations (FBOs) and the Private Sector. The document will also help the public at large to understand what the Government is doing to ensure optimal nutrition for Somalia population and what they can individually do to contribute to improved nutrition. This MSN has been organized into eight chapters as follows: Chapter 1 which is the introduction, includes the background, political and economic context under which the MSN is anchored, the 2019-2024 MSN development process including the review of the first Somali Nutrition Strategy (MoH-SNS; 2011-2013) which was developed under the vii imprimatur of the United Nations agencies working in nutrition, focused on seven priority outcomes that were all within the nutrition sub-sector. This iteration of the Somalia Nutrition Strategy is ambitious in its scope and in the depth of the results it seeks to achieve. It covers a range of interventions across relevant sectors which address the immediate, underlying and basic causes of malnutrition. A comprehensive situation Analysis of causality is presented in chapter 2 while chapter 3 presents priorities for MSN strategies including rationale for multisectoral approach, conceptual framework of the Somalia multisectoral nutrition strategy, expected results and key result areas strategies. Chapter 4 presents the challenges of implementing the strategy including rolling out and scaling up the strategy. Chapter 5 presents the coordination accountability, service delivery and prioritization including coordination mechanisms, agencies and accountability, service delivery structures for nutrition, target group and prioritization, targeting by livelihood zones and duration of multisectoral plan. Chapter 6 presents operational approaches. Chapter 7 presents capacity development assessment and strategy including capacity needs assessment and capacity development strategy, while chapter 8 presents monitoring and evaluation including introduction, MSN monitoring, MSN learning, MSN evaluation and common result framework. Moreover, the activities detailed in this Strategy aim to achieve seven priority objectives. The 7 strategic objectives are; 1. To create an enabling policy and legal environment necessary for improvement of nutrition outcomes across all the sectors both at national and sub national level: This Strategy seeks to implement actions that create an enabling environment that is fundamental to transformative approaches that work to reduce under nutrition. It is anticipated that activities under this objective will create an enabling environment that will turn commitments into results at the implementation level. These activities belong to the domains of political and policy processes that build and sustain momentum for the effective implementation of actions that reduce malnutrition in Somalia. 2.To create, strengthen and sustain sectoral and Multi-Sectoral Nutrition coordination mechanisms at national and sub-national levels: The causes of malnutrition are multisectoral in nature and require a broad range of humanitarian and development actors in different sectors to provide a comprehensive and accountable policy response. The sectors critical for the success of this Strategy include health, education, water and sanitation, agriculture and food security, industry and trade (food availability), women and child development and social protection. This Strategy suggests three practical ways for the Somalia government to ensure that functional and effective coordination mechanisms become a cornerstone of implementing the Strategy. These are: (a) multisectoral coordination must be a priority of the OPM and efforts are be put in place to ensure that conveners have a clear vision of the ‘big picture’ of the role of effective coordination, (b) coordination efforts should be guided by a practical strategy with well-defined roles and responsibilities for participating viii sectors and agencies with a system for monitoring activities with feedback mechanisms for coordination and overall management and (c) multisectoral nutrition stakeholders must be held responsible for collaboration results. 3. To improve and strengthen human resource capacity for providing appropriate support to maternal and child nutrition at national and sub-national levels: Increasing the capacity of the human resources for health and nutrition (through increasing the workforce, improving the balance of skills and strengthening capacities) is one of the building blocks of a well-functioning health system highlighted in the Somalia HSSP (and adopted from WHO building blocks of a functional health sector). Although the core of the HSSP Strategy is service delivery that is strongly tied to the implementation of the Essential Package of Health Services (EPHS) in four levels of service delivery (primary health care, health centre, referral health centres and hospital), this Multisectoral Nutrition Strategy goes beyond supporting the HSSP objectives to include the strengthening of capacities in sectors whose inputs can influence nutrition outcomes. This Strategy sets out to develop a nutrition workforce that addresses the priority needs of the Somali population, which is adequate in number, well trained, equitably distributed and motivated to provide essential health services. 4. To develop and integrate a full package of nutrition-specific interventions into basic health care services at national and sub-national levels: This objective seeks to improve access to essential nutrition services of acceptable quality through implementation of a core set of nutrition services (covered in the EPHS) to produce the desired outcomes. Achievement of this objective will effectively contribute to the reduction of maternal and child mortality by reducing malnutrition among pregnant women, lactating mothers and children under five years of age through integrating the delivery of nutrition services in the health and other nutrition-sensitive sectors. 5. To improve policy and practises that enhance maternal and child nutritional status through optimal use of nutrition-sensitive services: The 2013 lancet series on maternal and child under nutrition reviewed evidence of nutritional effects of programmes in four sectors: agriculture, social safety nets, early child development and schooling. 6. To address gender and social-cultural factors that hinder improvement of maternal, infant, and young child nutrition at national and sub national level: There are many socio- cultural issues that affect maternal, infant and young child nutrition - and restrictive gender roles in society is a key element of these. The links between mothers’ education and nutrition status of their children are well-established, highlighting that education of girls through secondary level and beyond is a critical intervention for establishing well- nourished households and communities. In addition, delaying first pregnancy beyond the adolescent years is a vital measure for the health and nutrition of girls and young women, as well as their children. 7. To strengthen organisational, institutional and policy framework for linking humanitarian relief, to recovery and development towards to nutrition improvement at national and sub national level: The concept of Linking Relief, Rehabilitation and Development explores ways to join up short-term life-saving humanitarian interventions ix and long-term efforts to reduce poverty, vulnerability and malnutrition. It is imperative for humanitarian relief to continue to meet the immediate needs of crises effected populations, including by reducing acute (severe and moderate) malnutrition and mortality. However, it is now widely recognised humanitarian relief needs to be formulated and delivered in ways that strengthen population resilience to future crises, states own capacity for emergency preparedness and response and facilitate the longer-term transition from humanitarian to longer-term development assistance. The integrated nature of the Multisectoral Nutrition Strategy will need an effective, harmonized and well-coordinated Monitoring and Evaluation (M&E) framework that assimilates and consolidates results from multiple sectors. This Strategy assumes strong collaboration among stakeholders to enable the development of an effective and shared monitoring, evaluation, accountability and learning (MEAL) framework applicable in the lifecycle of the Strategy. The M&E plan will aim to utilize existing data and information platforms from various sectors as much as possible to avoid duplication. The Process of implementation of the M&E Framework is envisioned that the SUN focal point at the OPM will commission the development of a monitoring and evaluation plan with clear linkages to existing data management systems and milestones for each of the seven strategic objectives. The plan should support the use of standardised methodologies and indicators that are already in use. In the absence of standardised methodologies, it is recommended that validated protocols developed by technical teams be employed. The support roles to strengthen M&E are envisioned for the Office of the Prime Minister in its role as a SUN convener. Learning will be inbuilt as a continuous aspect in the implementation process of the Multisectoral Nutrition Strategy. It is a critical programme component that should superordinate both monitoring and evaluative processes in the programme cycle. A component of learning will be embedded in each stage of implementation focusing on learning from both negative and positive experiences. To strengthen and support learning, it will be treated as a crosscutting theme and indicators related to learning developed at both higher and lower levels. The following aspects of programme learning will need to be incorporated in the implementation plans (national and sub-national). A mid-term evaluation after 2.5 years will be undertaken to determine the extent to which the objectives of the strategic plan are met, looking at - inputs/processes; outputs; outcomes and impact. It will cover all the targets mentioned in the plan, including targets MSN for outcome and impact indicators. The results will be used to adjust strategies, priorities and objectives. The end-term evaluation will be carried out at the end of the strategic period and lessons learnt will be used in the design of the new and follow-on strategy. The main aim of the end term evaluation will be to review final achievements of the nutrition sector against what was planned. It will involve a comprehensive analysis of progress and performance for the whole period of the plan. For the M&E framework to perform as envisaged, it is critical to develop consensus on a Common Results Framework (CRF). The CRF provides a summary of the objectives, x indicators and targets for monitoring progress in implementation. Being a multisectoral strategy, indicators will be drawn from all the sectors involved in nutrition interventions. Key elements that will support implementation of the MSN include a vibrant and functional regulatory environment supported by robust legal frameworks which provides for revision of existing legislation and formulating new laws and regulations and guidelines to ensure availability and accessibility of adequate, safe, and quality food and adherence to internationally recognized standards and nutritional guidelines. Optimization of coordination structures to facilitate and drive service delivery, capacity strengthening, evidence generation and utilization, advocacy and resource mobilization, resource tracking and social accountability. Sector wide partnerships are critical in the execution of the Multisectoral Nutrition strategy and for driving the vision of nutrition in the country. The strategy offers a chance of aligning all future and downstream policies and strategies around common objectives and coordination structures. This will improve both policy and operational coherence. xi TABLE OF CONTENTS 1. INTRODUCTION ................................................................................................................................... 1 1.1. BACKGROUND ............................................................................................................................. 1 1.1. POLITICAL CONTEXT .................................................................................................................... 1 1.1. NUTRITION CONTEXT .................................................................................................................. 2 1.2. ECONOMIC CONTEXT .................................................................................................................. 2 1.3. SOMALIA MULTISECTORAL NUTRITION STRATEGY DEVELOPMENT ............................................ 2 2. SITUATION AND ANALYSIS OF CAUSALITY........................................................................................... 5 2.1. INTRODUCTION ........................................................................................................................... 5 2.2. NUTRITION STATUS ..................................................................................................................... 5 2.3. POLICY STATUS ............................................................................................................................ 7 Nutrition-Specific Policies ................................................................................................................... 8 Nutrition-Sensitive Policies ................................................................................................................. 9 2.4. DRIVERS OF MALNUTRITION ..................................................................................................... 10 3. PRIORITIES FOR MSN STRATEGY ....................................................................................................... 15 3.1. RATIONALE FOR A MULTISECTORAL APPROACH ....................................................................... 15 3.2. CONCEPTUAL FRAMEWORK OF THE SOMALIA MULTISECTORAL NUTRITION STRATEGY.......... 16 3.3. EXPECTED RESULTS, KEY RESULT AREAS, STRATEGIES .............................................................. 19 ROLLING OUT AND SCALING UP THE STRATEGY ....................................................................................... 49 4. COORDINATION, ACCOUNTABILITY, SERVICE DELIVERY AND PRIORITISATION ................................. 50 Coordination Mechanisms .................................................................................................................... 50 Agencies and Accountability ................................................................................................................. 50 Service Delivery Structures for Nutrition-Specific and -Sensitive Interventions ................................... 52 Target Groups and Prioritisation ....................................................................................................... 53 Targeting by Livelihood Zones........................................................................................................... 53 Duration of Multisectoral Plan .......................................................................................................... 53 5. OPERATIONAL APPROACHES............................................................................................................. 55 6. CAPACITY DEVELOPMENT, ASSESSMENT AND STRATEGY ................................................................. 57 Capacity needs assessment................................................................................................................... 57 Capacity development strategy ............................................................................................................ 58 xii 7. MONITORING, EVALUATION AND LEARNING.................................................................................... 60 7.1. Introduction .............................................................................................................................. 60 7.2. MSN Monitoring........................................................................................................................ 62 7.3. MSN Learning ............................................................................................................................ 63 7.4. MSN Evaluation ......................................................................................................................... 63 7.5. The common results framework (CRF) ...................................................................................... 65 8. RISK ASSESSMENT, ANALYSIS AND MITIGATION ................................................................................... 67 8.1 Risk identification, assessment and prioritization ........................................................................... 67 8.2 Risk Analysis Frameworks ............................................................................................................... 67 8.2.1 SWOT Analysis in managing risk ............................................................................................... 67 8.2.2 PESTLE Analysis in managing risk ............................................................................................. 68 8.3 Risk Mitigation Measures ................................................................................................................ 69 8.4 Combined risk Analysis, evaluation, prioritization and mitigation measures matrix....................... 69 8.5 Potential bottlenecks to the implementation of the strategy ......................................................... 74 BIBLIOGRAPHY .......................................................................................................................................... 76 ANNEXES ................................................................................................................................................... 78 ANNEXES ................................................................................................................................................... 79 ANNEX 1: METHODS ............................................................................................................................. 79 ANNEX 2: COMMON RESULTS FRAMEWORK ........................................................................................ 80 ANNEX 3: STAKEHOLDER CONSULTATIONS........................................................................................... 98 xiii List of tables Aga Khan University Table 1. Core components of the proposed M&E framework. ........................................... 60 Table 2: Risk assessment prioritization matrix ........................................................................... 67 Table 3: Risk analysis, mitigation and accountability table for the SMNS........................... 70 xiv List of figures Figure 1. GAM prevalence in Somalia, 2007 – 2016................................................................. 6 Figure 2. Stunting prevalence in Somalia, 2013 – 2016. ........................................................... 6 Figure 3. Drinking water and sanitation levels, 2015 (%), ...................................................... 10 Figure 4. Somalia livelihood zones. ........................................................................................... 13 Figure 5. UNICEF conceptual framework on the determinants of child malnutrition, 2015. ....................................................................................................................................................... 16 Figure 6. The goal, strategic objectives and expected results for the Strategy. ............... 21 Figure 7. Odds ratio for mortality in wasted children. ............................................................ 27 Figure 8: Logical Model for M&E ............................................................................................... 60 Figure 9: Nutrition Data Value Chain ....................................................................................... 62 Figure 10: SWOT analysis for the SMNS ..................................................................................... 68 xv ACRONYMS AKU Aga Khan University BEmOC Basic Emergency Obstetric Care BPHNS Basic Package of Health and Nutrition Services BSNP Basic Nutrition Services Programme CEDAW Convention on the Elimination of All Forms of Discrimination against Women CEmOC Comprehensive Emergency Obstetric Care CHDS Child Health development services CHWs Community Health Workers CMAM Community Management of Acute Malnutrition IMAM Integrated Management of Acute Malnutrition CSN Civil Society Network DHIS District Health Information System DFID Department for International Development DI Development Initiatives ECD Early Childhood Development EU European Union EPHS Essential Packages of Health Services FAO Food and Agriculture Organization FCHWs Female Community Health Workers FGM Female Genital Mutilation FGS Federal Government Somalia FSNMS Food Security and Nutrition Monitoring System GAM Global Acute Malnutrition GNI Gross National Income HC Health Centre HMIS Health Management Information System HPF Humanitarian Pooled Fund xvi HPI Health Partners International HSDP Health Sector Development Plan HSSP Health Sector Strategic Plan ICCM Integrated Community Case Management IDP Internally Displaced Persons IYCF Infant and Young Child Feeding IYCN Infant and Young Child Nutrition IUG Intrauterine Growth Restriction MAM Moderate Acute Malnutrition MCH Mother and Child Health MCHN Mother and Child Health and Nutrition M&E Monitoring and Evaluation MQSUN+ Maximising the Quality of Scaling Up Nutrition Plus MICS Multiple Indicator Cluster Surveys MIYCN Maternal, Infant and Young Child Nutrition MNCH Maternal, Neonatal and Child Health MOECHE Ministry of Education, Culture and Higher Education MOH Ministry of Health MSN Multisectoral Nutrition SMNS Somalia Multisectoral Nutrition strategy MSP Multisectoral Plan NDP National Development Plan NIMS Nutrition Information Management Systems OTP Outpatient Therapeutic Programme OPM Office of the Prime Minister PHCC Primary Health Care Centres PHCU Primary Health Care Units SUN Scaling Up Nutrition Movement WHO World Health Organization xvii WRA Women of reproductive age 1 1. INTRODUCTION 1.1. BACKGROUND The population of Somalia is estimated at 14.3 million people and life expectancy at birth is estimated at 56 years. In 2014, 42 percent of the total population were living in urban areas and 23 percent in rural areas. The nomadic population constituted 26 percent of the population and internally displaced persons (IDP) nine percent. The Gross National Income (GNI) per capita is US$ 434. In 2012, after more than two decades of civil conflict, a federal government emerged in Somalia. The government adopted a new constitution which establishes the country as a federation in which two or more regions can unite to form a state.4 The country is currently divided among six states of Puntland, Galmudug, Jubaland, South West State, Hirshabelle and Somaliland, as well as the administrative region of Banadir (Mogadishu). While States are constitutionally subject to the authority of Federal Government, they have considerable independence on many issues. State governments in Somaliland and Puntland have judiciary, legislative and executive systems, and related state ministries in place. For administrative and planning purposes the country is divided into three main zones, and 18 administrative regions, which in turn are divided into districts. 1.1. POLITICAL CONTEXT The country remains in a volatile security situation and the government continues to face a violent insurgency, concentrated in the country’s central and southern regions. Deep clan divisions fuel sporadic inter-clan conflicts while further insecurity is caused by non-state armed groups who continue to have de-facto control in large areas of the country. Vulnerability to extreme climate events also remains a key driver of humanitarian need in the country. This vulnerability and food and nutrition insecurity in the country is indirectly linked to the clan structure which permeates the country’s wider economic and political structures. Clan identities are linked to social marginalisation and more sedentary and agriculturally based livelihoods reliant on rain and surface water for irrigation. Livelihood profiles and pervasive poverty within some clans leaves these populations especially vulnerable to climatic, economic and conflict induced shocks.18 Despite these challenges, Somalia continues to experience increasingly strong political, economic and institutional growth. A peaceful election and transition of power to Federal President Mohamed Abdullahi Mohamed and the formation of a new cabinet under the Prime Minister in 2017, were important political milestones.5 A range of policies and strategies have also been developed in nutrition relevant sectors. However, a clear delineation of roles and responsibilities between and within Federal and State ministries and institutions is, in many areas, still emerging. 2 The backdrop in the attempt to plan for longer-term development in Somalia was defined by fragility of the State and a multidimensional conflict that negatively impacted on the fight against extreme poverty, food insecurity and contributed to poor nutrition outcomes. The decades of fragility and conflict led to the collapse of the formal health sector and the emergence of various fragmented and parallel health systems and infrastructures that have been unable to overcome the significant barriers to accessing quality nutrition care and support for most of the population, particularly for the most vulnerable subgroups in the population. 1.1. NUTRITION CONTEXT Nutrition is a major problem in Somalia, with prevalence of acute malnutrition consistently above World Health Organization (WHO) emergency thresholds, high levels of micronutrient deficiencies and extremely poor infant and young child feeding practices. This situation contributes substantially to high morbidity, mortality and overall disease burden in the country. The persistence of undernutrition also places a large burden on the struggling health care system (directly or through contributing to the burden of disease) and seriously impedes the realisation of Somalia’s economic and human development potential. 1.2. ECONOMIC CONTEXT Somalia’s economy is projected to grow at a steady, nominal annual rate of 5 to 7 percent over the medium-term. Despite this continued economic growth, the economy remains largely sustained by donors' grants, remittances, and foreign direct investment mostly by the Somali diaspora. Multidimensional poverty remains severe and widespread. 1.3. SOMALIA MULTISECTORAL NUTRITION STRATEGY DEVELOPMENT The Government of Somalia has developed this Multisectoral Nutrition (MSN) Strategy to facilitate further cooperation across sectors towards improving nutrition outcomes for the Somali Population. The Strategy has been developed to buttress existing policy initiatives and build a stronger and coherent basis for a future with stronger prospects for economic and social development. 3 Rather than fragmenting or duplicating policy and planning, this Strategy and underlying Common Results Framework seek to consolidate the already existing set of policies in place across sectors which can contribute to the eradication of malnutrition in Somalia. To this end, the Strategy seeks to complement the existing policy objectives of the Somali government, particularly the main objectives outlined in the • National Development Plan(PLAN and 2019, 2016), • the Health Sector Development Plan, • Somali Health Policy (WHO-Somalia, 2014), • Basic Package of Health and Nutrition Services (MOH-FGS/UNICEF), • National Infant and Young Child Feeding Strategies (Strategy and Plan Somalia, 2013), (Puntland, 2012)), (Somaliland, 2012) • National Guidelines for Community Management of Acute Malnutrition (CMAM) and • Somalia National Micronutrient Deficiency Control Strategy (SMS, 2016). Furthermore, it sets forth an ambitious agenda for the initiation, scale up, alignment and harmonisation of future policy and action. The Strategy encompasses activities from all six WHO building blocks for health system strengthening and has a strong focus on cross-sectoral integration and coordination. The Strategy also spells out the programme principles that the government and stakeholders should employ in pursuit of included results. The activities detailed in this Strategy aim to achieve seven priority objectives and associated intermediate outcomes and targets that will contribute to improved nutrition status among pregnant women, lactating mothers and children under five years of age directly through health sector actions and indirectly through other ‘sensitive’ sectors. The seven priority objectives are: 4 1. To create an enabling policy and legal environment necessary for improvement of nutrition outcomes across all the sectors both at national and sub national level 2. To create, strengthen and sustain sectoral and Multi-Sectoral Nutrition coordination mechanisms at national and sub-national levels. 3. To improve and strengthen human resource capacity for providing appropriate support to maternal and child nutrition at national and sub-national levels. 4. To develop and integrate a full package of nutrition-specific interventions into basic health care services at national and sub- national levels 5. To improve policy and practises that enhance maternal and child nutritional status through optimal use of nutrition-sensitive services. 6. To address gender and social-cultural factors that hinder improvement of maternal, infant, and young child nutrition at national and sub national level. 7. To strengthen organisational, institutional and policy framework for linking humanitarian relief, to recovery and development towards to nutrition improvement at national and sub national level. Photo credit: Courtesy of Photoshare, 2014 5 2. SITUATION AND ANALYSIS OF CAUSALITY 2.1. INTRODUCTION The first Somali Nutrition Strategy (MoH-SNS; 2011-2013), developed under the imprimatur of the United Nations agencies working in nutrition, focused on six priority outcomes that were all within the nutrition sub-sector. This iteration of the Somalia Nutrition Strategy is ambitious in its scope and in the depth of the results it seeks to achieve. It covers a range of interventions across relevant sectors which address the immediate, underlying and basic causes of malnutrition. 2.2. NUTRITION STATUS Globally, over one third of all child deaths are linked to malnutrition, yet progress to tackle all forms of malnutrition remains unacceptably slow. Childhood stunting is gradually declining, indicting some progress. However, 150.8 million children are still stunted, 50.5 and 38.3 million children are wasted and overweight respectively, and 2.01 billion adults are overweight and obese. Further, 3.62 percent (15.95 million) of children under five are both stunted and wasted, while 1.87 percent (8.23 million) of under-fives globally experience both stunting and overweight.1 Eighty eight percent of countries experience more than one form of malnutrition, with 29 percent having high levels of all three forms. Less than half of the countries are on course to meet at least one of nine global nutrition targets, with no country being on target to meet all the nine targets that are being tracked. In addition, no country is on course to meet the adult obesity target.2 Anaemia prevalence in girls and women of reproductive age remains high at 32.8 percent; with a global prevalence in pregnant women decreasing from 41.6 percent in 2000 to 40.1 percent in 2016 and a prevalence of non-pregnant women at 32.5 percent, from 31.1 percent over the same time.3 Two billion people lack key micronutrients like iron, vitamin A and iodine. Another two billion adults and 38.3 41 million children are overweight. It is also estimated that the total cost of malnutrition is about 3.5 trillion USD per year and that the world is off-track to meet all the global nutrition targets. Nationally, despite more than two decades of widespread conflict, Somalia has in recent years made significant political and economic progress with the establishment of permanent political, economic and security institutions. Despite positive prospects for a more peaceful and prosperous future, the country continues to face an ongoing protracted humanitarian emergency and alarmingly high levels of Global Acute Malnutrition (GAM) (Figure 1). 1 Global nutrition report, 2018 2 Global nutrition report, 2018 3 WHO, Global Health Observatory Data Repository, http://apps.who.int/gho/data/?theme=main. 6 Figure 1. GAM prevalence in Somalia, 2007 – 2016. Food Security and Nutrition Analysis Unit - Somalia. FSNAU Technical Series Report Post Gu-2016-Nutrition Analysis. United Nations Food and Agriculture Organization, 2017. Large areas of the country, particularly the South-Central zone, which accounts for approximately 60 percent of the Somali population, have experienced persistently high levels of GAM since nutrition surveys first started being conducted in the country in the early 1980s. This persistently high “background prevalence” of acute malnutrition has been accompanied by intermittent periods of widespread severe hunger and excess mortality driven by climatic shocks and political and civil conflict.7 For much of 2017 median national prevalence of GAM was above the WHO emergency thresholds of 15 percent. Chronic malnutrition (stunting), while less prominent than acute malnutrition, remains a serious problem in Somalia. Estimates between 2013 and 2016 (Figure 2) consistently show a median prevalence between 10 and 20 percent. The country lags both national and World Health Assembly (WHA) Targets to reduce stunting to 0.15 million children by 2019 and 0.32 million children by 2025 respectively. Figure 2. Stunting prevalence in Somalia, 2013 – 2016. 7 Food Security and Nutrition Analysis Unit - Somalia. Nutrition Analysis 201318, 201419, 201519, 201619. United Nations Food and Agriculture Organization, 2017. Recent data on the micronutrient status of the population are sparse. However, a 2009 survey10 showed high levels of micronutrient deficiencies throughout much of the country. Iron deficiency in women of childbearing age was over 41 percent; 59 percent in children under-5 and 74 percent in children under two, while Vitamin A deficiency rates were 33 percent among women and children under five. Since the survey was conducted, several programmes to combat micronutrient deficiency have been implemented and/or scaled up. These include semi-annual Vitamin A supplementation for children aged 6-59 months through routine and mass community-supplementation initiatives, as well as supplementation for prevention and treatment of anaemia in pregnant and lactating women through provision of iron, folate and multiple micronutrient tablets. Infant and Young Child Feeding (IYCF) indicators have shown significant improvement in recent years. A 2016 nationally representative survey found 30 percent of women reported exclusively breastfeeding their child for six months, up from just over 5 percent in 2009. However, this figure still falls short of the global average of 46 percent and the WHA target of an exclusive breastfeeding rate of 50 percent, to be achieved by 2025. The 2016 survey found IYCF indicators to be poorer, in almost all cases, in the South- Central zone than in other regions. 2.3. POLICY STATUS This Strategy sets out to consolidate and integrate various policy instruments of the Somali government that seek to tackle undernutrition. It extends beyond the health sector to include policies in other sectors seeking to ensure the (current or future) 8 alignment of all government policies tackling undernutrition while at the same time eliminating fragmentation of policies. The Strategy builds on the following existing policy and operational documents of the Somalia government: Nutrition-Specific Policies I. The National Development Plan (NDP): The NDP outlines several proven and cost-effective nutrition-specific interventions integrated where possible into the wider set of health interventions under the country’s Essential Package of Health Services. Identified priority interventions include enhanced and expanded quality services for the management of acute malnutrition and treatment of micronutrient deficiencies. It aspires to increase access to and utilisation of micronutrient supplements, fortified supplementary food among vulnerable groups and deworming interventions through health campaigns, health facilities, schools, outreach programmes, and other nutrition programmes. Food based interventions are to be implemented and scaled up to prevent undernutrition in identified high risk populations. II. The Health Sector Strategic Plan (HSSP)(Ingles, Legare and Lautt, 1994): The MSN Strategy supports and builds on the six HSSP strategies recognised as building blocks of a well-functioning health system. These include leadership and governance, human resources for health, service delivery, financing, products and technology and information and research. III. Essential Package of Health Services(Pearson and Muschell, 2009): Nutrition is covered as a sub-programme in the following core programmes (a) maternal, reproductive and neonatal health programme that supports nutrition activities related to maternal nutrition, supplementary feeding and neonatal nutrition (b) child health programme that supports nutrition activities that include infant and young child nutrition, nutrition screening, micronutrient supplementation, management and treatment of severe acute malnutrition and anaemia control. IV. Somali Health Policy (WHO-Somalia, 2014): The MSN Strategy supports the Somali Health Policy directives to revitalise health services through four policy shifts, the first of which is to “strengthen reproductive, Maternal, Neonatal, Child Health (MNCH) and Nutrition” through revitalising the EPHS implementation and improving the health system capacity to combat maternal and child malnutrition by promoting appropriate knowledge, attitudes and practices on maternal nutrition, infant and neonatal feeding, including exclusive breastfeeding and complementary feeding practices and preventing disease and undernutrition through access to micronutrient supplements, deworming and hygiene and sanitation. The MSN Strategy supports and contributes to the overall goal of the Somali Nutrition Strategy ((MoH-SNS; 2011-2013, no date)) of improving the survival and development 9 of Somali people through enhanced nutritional status which is to be accomplished through nutrition-specific interventions. V. The Basic Package of Health and Nutrition Services (BPHNS): The MSN Strategy supports the Nutrition Services Package (BNSP) that is centred on a holistic life-cycle approach that combines treatment and promotion of optimal nutrition, including management of acute malnutrition. The basic nutrition services package for Somalia was designed to promote consensus around guiding principles for the implementation of basic nutrition services packages at various levels of the Health System and throughout the lifecycle. VI. Operational documents that incorporate actions supported by the MSN Strategy include: • National Infant and young Child Feeding Strategies (Strategy and Plan Somalia, 2013), (Somaliland, 2012), (Puntland, 2012). • National Guidelines for Community Management of Acute Malnutrition (CMAM). • Somalia National Micronutrient Deficiency Control Strategy (2014 – 2016). Nutrition-Sensitive Policies Recent progress in policy development in nutrition-sensitive sectors include the Agriculture and Food Security Strategy, the federal Health Sector Strategy and the community health worker strategy among others. However, policies in areas of key importance to nutrition such as WASH and social protection are still under development. The Somali Federal Ministry of Agriculture was established in 2014. Prior to this, agriculture had been under the remit of the Ministry of Natural Resources for almost two decades.15 The newly formed ministry has been tasked with ensuring the effective and sustainable use of national resources to spearhead economic recovery - the central pillar among the NDP’s six main pillars. The Federal Government's stated Vision for the agriculture sector is “to ensure food and nutrition security and to pursue economic growth, social capital development (youth and women empowerment and involvement in agricultural activities) while reducing the process of environmental degradation”. There are three strategic areas of focus around which the Ministry of Agriculture’s objectives and strategies are derived. These are set forth in the Ministry’s Agriculture Strategic Plan 2016-2020 (Sultan Amri MOA, 2016) and are accompanied by a number of sub-goals. While social protection programmes play an increasingly important role in humanitarian assistance in Somalia, no national Government social protection programme is in place. However, a UN-led inter-agency Cash Working Group is working with the government to identify which elements of the social protection 10 system used by humanitarian and development actors could be transitioned to a government-run, nutrition-sensitive social protection programme. As the capacity of Somali institutions continues to grow, attention is increasingly focused on linking humanitarian assistance to longer-term development programming and increasing national capacity and ownership. Facilitating the delivery of lifesaving humanitarian assistance in a way that strengthens state institutions and reduces long- term population vulnerability is a key aim of this MSN Strategy. Hence, there is already a strong normative framework in place in Somalia for achieving this aim. The NDP pillar on resilience seeks to reduce the humanitarian caseload through bringing together actors with developmental solutions and priorities in place of humanitarian actions. The NDP lays forth a plan for the establishment of Coordination Committees for humanitarian action at federal and regional-state levels enabling coordination and collaboration across line ministries, UN agencies and non- governmental organisations (NGOs). The Federal Ministry of Planning and International Cooperation is preparing operational guidelines for these committees which will set forth how collaboration will occur in practice. Relevant Cluster partners are working closely with regional and federal disaster management departments to strengthen capacity in monitoring, needs assessments, early warning and response mechanisms, targeting, and response coordination. As government capacity is steadily improving, the roles and responsibilities of the various ministries within humanitarian coordination and implementation efforts are in most areas evolving. This provides an opportunity for integrating accountability for nutrition from an early stage of institutional development. The formulation of national emergency preparedness policy, strategy and structures provides further opportunity for incorporating best practice in nutrition response and experiences from similar country contexts. 2.4. DRIVERS OF MALNUTRITION WATER AND SANITATION: Children’s health and nutritional well-being are strongly linked to their access to safe water and proper sanitation and hygiene (Figure 3). In 2015, an estimated 60 percent of the Somali population lacked access to an improved source of drinking water while access to improved sanitation was among the lowest in the world with less than 20 percent of the population accessing an improved sanitation source. Figure 3. Drinking water and sanitation levels, 2015 (%), 11 WHO & UNICEF Joint Monitoring Programme. Somalia Drinking water and sanitation levels 2015 (%). Accessed 18/04/2018. https://washdata.org/data#!/som,. Water delivered through water trucking is common in urban and IDP settings; in addition, commercial taps provide an important source of water in IDP camps. Both water trucking and commercial taps are often costly, unreliable and have sub-optimal water treatment jeopardising the health of users. Almost no government piped water supply or sanitation sector exists outside of urban centres. Most of the country locations remain without effective water supply and sanitation institutional organisation or oversight. AGRICULTURE: Somalia is at an early stage of economic development and agriculture continues to play a central role in the country’s economy (see Map of Somalia livelihood zones in Figure 4). Despite the economic and cultural importance of agriculture, the country remains highly food insecure at the macro level. A 2018 World Bank review of the sector found the country’s food crop deficit has drastically increased in recent decades. Local production, on average, meets less than a quarter of per capita cereal needs per year, and not more than half of needs in years when maximum production is achieved. ENVIRONMENT: Recurrent and prolonged drought, together with inadequate production of climate resilient crops has severely impacted livelihoods especially among pastoralists and rural populations reliant on livestock production for their income and own consumption. Climate change is likely playing an important role in the increasing frequency and severity of droughts in Somalia and the wider horn of Africa region in recent years. This situation is further exacerbated by the widespread reliance on rainwater for agricultural and livestock production and a reliance on rain fed aquifers and surface water as drinking water sources. https://washdata.org/data#!/som 12 The impact of drought and water scarcity on livelihoods has led to widespread population displacement from rural to urban and peri-urban areas. This has in turn resulted in increased pressure on municipalities in receiver areas to provide basic services such as Water, Sanitation and Hygiene (WASH), health, education and adequate shelter and living space. The resulting increased lack of potable water, inadequate sanitation and hygiene and strain on health infrastructure has driven increased prevalence of acute malnutrition and sporadic disease outbreaks, especially acute watery diarrhoea/cholera and measles.17 EDUCATION, SOCIAL AND CULTURAL STATUS: Conflict and poor governance have also exerted a heavy toll on the country’s education system. The overall adult literacy rate declined significantly between 1975 and 2014, falling from 54 percent to 40 percent. A 2016 report20 from the UNFPA found the gross enrolment rates for primary school‐ aged children are among the lowest in the world with 30 percent of children enrolled in primary education level and 26 percent in secondary education. Education Attainment is estimated at 3.1 years.4 Primary barriers to education are poor security and an associated lack of safe spaces for learning, insufficient numbers of both qualified and unqualified teachers and little oversight or reach of the Ministry of Education (MOE), among others.21 Girls represent less than half of Somali students and only a quarter of women aged between 15 and 24 are literate, compared with 37.8 percent of men. The low availability of sanitation facilities (especially separate latrines for girls), a lack of female teachers (less than 20 percent of primary-school teachers in Somalia are women), safety concerns and social norms that favour boys’ education are cited as factors inhibiting parents from enrolling their daughters in school. Women in Somalia face widespread and severe social and economic discrimination. The country has high rates of violence against women, Female Genital Cutting (FGC), child marriage, maternal mortality and rape. In many areas of Somalia customary law (Xeer) and religious law (Sharia) operate in place of or alongside the secular state legal system. Historically, women are suffering discrimination within customary legal processes and are not permitted a voice within them. Somali customary laws also often circumvent women's inheritance rights with property passing between the patriarchal family. When empowered, women are more likely than men to make decisions which are more beneficial for the nutrition of children and the wider household. Programmes designed to improve women’s education, increase women’s decision-making power and ability to prioritise their health and well-being, thus powerful knock-on effects on the nutrition of both the wider household and future generations. Many of these drivers of malnutrition in Somalia—food insecurity, water stress, conflict, low levels of education, women’s low social status and poor childcare and nutrition 4 Global burden of disease, 2017, http://www.healthdata.org/somalia 13 practices—are closely intertwined. Solutions to address these drivers thus call for a broad-based multisectoral response. EPIDEMIOLOGIC STATUS: The country remains at an early stage of epidemiological transition and communicable diseases remain major causes of mortality. The year 2017 saw major outbreaks of cholera and measles in the country. The Somali conflict inflicted a heavy toll on the country’s healthcare system, negatively affecting both public and private sector health infrastructure and displacing health professionals. The health workforce density is among the lowest in the world.19 Figure 4. Somalia livelihood zones. 14 15 3. PRIORITIES FOR MSN STRATEGY 3.1. RATIONALE FOR A MULTISECTORAL APPROACH The case for investing in nutrition is clear. Poor nutrition, during the first 1,000 days of life - from pregnancy through age two - can cause life-long and irreversible damage, negatively impacting the individual, community, and wider national development. The SUN movement advocates for a multisectoral approach to address malnutrition, scaling up both nutrition “specific” and nutrition “sensitive” sectors.26 Nutrition-specific interventions are those which address immediate causes of malnutrition, for instance through management of acute malnutrition, micronutrient supplementation, management and control of infections, and nutrition education and behaviour change communication to prevent undernutrition. Such interventions are vital to reduce immediate risk of mortality and serious morbidity. However, to address the drivers of malnutrition requires addressing the underlying and basic causes of malnutrition. This necessitates a broad range of actions such as increasing access to affordable nutritious food, clean water, sanitation, healthcare and social protection. It is notable that social and behaviour change communication programmes, such as the Somalia Social Mobilisation Advocacy and Communication Strategy, have the potential to address both underlying and immediate causes of malnutrition. Nutrition-sensitive programmes or sectors have the power to address the underlying and basic causes of malnutrition by: - • Explicitly including nutrition in the objectives, design, implementation and monitoring and evaluation of policy and programmes. For example, including nutrition objectives and targets in policy and programmes across related sectors. • Prioritising interventions known to have a positive effect on nutrition outcomes in policy and programmes. For example, providing potable drinking water and improved sanitation facilities or promoting biofortified or other nutritious food crops over less notorious varieties in agriculture. • Targeting interventions across sectors, geographically or for socio-economic groups in order to reach nutritionally vulnerable households and household members. • Creating linkages between nutrition services and other sectors. For example, assuring households accessing nutrition services are also eligible for other social protection programmes and services and, in turn, using conditionality for other social programmes to increase demand for nutrition services. • Focusing on the empowerment and well-being of women and girls, especially pregnant, lactating and adolescent women. This is paramount to improving nutrition in several ways. The health and well-being of mothers pre- and post- conception impacts the health of their children. 16 The Scaling Up Nutrition (SUN) Movement was established to bring actors from across sectors in government, civil society and academia to scale up both nutrition-specific and nutrition-sensitive interventions. Due to the cross-cutting nature of nutrition, integrating nutrition into policy in relevant sectors is key to meaningful multisectoral action. A clear delineation of roles and responsibilities between and within federal and state ministries and institutions is emerging. Bringing actors from government, the private sector and international assistance together under a shared framework for planning, implementation and measurement of progress is vital to speeding up progress towards improving nutrition and health of Somalia’s population and its long- term prospects for a prosperous and healthy future. Target setting at both national and sub-national levels will help drive action on nutrition; and setting targets that are specific, measurable, achievable, relevant, and time bound (SMART) will help ensure focus and accountability among relevant actors.23 For this to work, SMART target-setting will need to be complemented with appropriate and effective Nutrition Management Information Systems, NMIS. Together these steps are vital to speeding up progress towards the improvement of the nutrition status of Somalia’s population and its long-term prospects for a healthy future. 3.2. CONCEPTUAL FRAMEWORK OF THE SOMALIA MULTISECTORAL NUTRITION STRATEGY This Strategy has been developed in line with the UNICEF 1990 framework of the causes of maternal and child undernutrition(Levitt, Pelletier and Pell, 2009) (Figure 5). This is consistent with the use of the UNICEF framework in child and maternal health and nutrition policy and programming more generally both within Somalia and globally. Figure 5. UNICEF conceptual framework on the determinants of child malnutrition, 2015. 17 The Framework conceptualises undernutrition and child death as being two manifestations of a multisectoral development problem that can be analysed in terms of the immediate, underlying and basic causes. It clearly outlines the causal relationship between multidimensional poverty, deprivation and undernutrition. It has proved to be a powerful tool in assessment; design and implementation of nutrition policy and programming through its recognition of the need to go beyond a curative approach to addressing undernutrition, to address the causes rooted in multidimensional poverty and deprivation (i.e. underlying and basic causes of undernutrition). This framework is thus in itself a clear reason and explanation for the need to adopt a multisectoral approach to elimination of malnutrition in Somalia. This Strategy is strongly reflective of universally accepted best practices and evidence- based interventions to address immediate, intermediate and basic causes outlined in the UNICEF framework. Most of the nutrition-specific interventions are informed by evidence from the Lancet Series on maternal and child undernutrition (2008 and 2013) (Horton and Lo, 2013)and many also correspond to those acknowledged by the Copenhagen consensus 2008 as the most cost-effective interventions for global development. The Strategy prioritises these proven effective interventions while taking into consideration feasibility, appropriateness and adaptability to the Somalia context. 18 EXPECTED RESULTS, KEY RESULT AREAS AND KEY STRATEGIES Photo credit: Courtesy of Photoshare, 2015 19 3.3. EXPECTED RESULTS, KEY RESULT AREAS, STRATEGIES The strategic objectives and expected results have been developed in response to the set of challenges faced in Somalia and encompass outcomes and activities that are considered most likely to lead to improved nutrition outcomes considering the evidence base. The Strategy goes beyond preventive and curative nutrition interventions and encompasses actions from sectors ‘outside’ the Maternal Child Health (MCH) agenda to those that can provide a basis for accelerating progress or act as entry points for nutrition interventions (nutrition-sensitive sectors) (Figure 6). The Strategy contains the following specific outcomes: creating an enabling environment to achieve the results outlined in the common framework of desired cross-sectoral results; building an effective coordination and collaboration framework at national and sub-national levels; strengthening the human resource capacity to deliver targeted results; addressing gender and socio-cultural issues that inhibit progress in Maternal and Child Health and Nutrition (MCHN) outcomes; and strengthening resilience through asset building and income generation for households. When combined with the outcomes of an effective Somalia Social Mobilisation, Advocacy and Communication (SMAC) Strategy, these activities will increase knowledge, foster change in attitudes and key practices (outcomes) proven to positively impact the health and nutritional status of young children in the first 1,000 days of life. Goal To reduce malnutrition through direct MCHN interventions and indirectly through nutrition-sensitive interventions that reduce poverty and food insecurity. Expected Impact By the end of the multisectoral nutrition programme cycle, nutrition-specific and nutrition-sensitive interventions will effectively contribute to improved nutrition outcomes especially in the first 1,000 days of life and in early childhood up to 5 years of age. It is expected that the proportion of under five children who are stunted will decrease from the estimated 12 percent to seven percent consistently with the aspirations in the current National Development Plan (NDP); while those wasting will decrease to below WHO emergency levels; and more than half of the under-five cohort will be consuming the minimum acceptable diet. Strategic Objectives The multisectoral and strategic objectives (SO) were identified by stakeholders from relevant sectors and line ministries in the Somalia government who expressed an aspirational prospect of attaining and sustaining the Strategy’s outcomes in the short- and medium- terms. The strategic objectives were identified with a recognition of the urgent need for a paradigm shift in Somalia to re-align all relevant actors towards accelerating progress in achieving human, economic and institutional development underscored by an adequately nourished and healthy population living beyond extreme poverty and hunger. 20 The Somalia Multisectoral Nutrition Strategy envisions the following seven strategic objectives; 1. To create an enabling policy and legal environment necessary for improvement of nutrition outcomes across all the sectors both at national and sub national level. 2. To create, strengthen and sustain sectoral and Multi-Sectoral Nutrition coordination mechanisms at national and sub-national levels. 3. To improve and strengthen human resource capacity for providing appropriate support to maternal and child nutrition at national and sub-national levels. 4. To develop and integrate a full package of nutrition-specific interventions into basic health care services at national and sub-national levels 5. To improve policy and practises that enhance maternal and child nutritional status through optimal use of nutrition-sensitive services. 6. To address gender and social-cultural factors that hinder improvement of maternal, infant, and young child nutrition at national and sub national level. 7. To strengthen organisational, institutional and policy framework for linking humanitarian relief, to recovery and development towards to nutrition improvement at national and sub national level. 21 Figure 6. The goal, strategic objectives and expected results for the Strategy. 22 To create an enabling policy and legal environment necessary for improvement of nutrition outcomes across all the sectors both at national and sub national level. This Strategy seeks to implement actions that create an enabling environment that is fundamental to transformative approaches that work to reduce undernutrition. It is anticipated that activities under this objective will create an enabling environment that will turn commitments into results at the implementation level. These activities belong to the domains of political and policy processes that build and sustain momentum for the effective implementation of actions that reduce malnutrition in Somalia. SO 1 Priority Areas The key policy priorities under this objective include: 1. To identify key nutrition actions in the Multisectoral Nutrition Strategy and integrate them into policy and planning processes across nutrition-sensitive sectors at national and sub-national levels. 2. To develop National and sub-national implementation plans and associated M&E frameworks. 3. To develop and implement a Somalia Social Mobilisation, Advocacy and Communication (SMAC) Strategy. 4. To build and strengthen the institutional capacity of nutrition authorities at both central and regional levels to provide strong leadership, effective governance and coordination to enable stakeholders to provide core nutrition functions that bear results. SO 1 Interventions • Launch the Multisectoral Nutrition Strategy and Common Results Framework and disseminating it at national and sub-national levels. • The Federal Government and member States develop detailed multisectoral nutrition plans with sub-national implementation plans, financial and monitoring and evaluation frameworks to be in place by the end of 2019. • Review and update the sectoral policies to incorporate nutrition-specific and nutrition-sensitive interventions and indicators by the Federal Government and member States’. • Include nutrition-specific and -sensitive monitoring and evaluation frameworks in sectoral annual work plans include. • Implement the Somalia Social Mobilisation, Advocacy and Communication (SMAC) Strategy that targets major stakeholders across various sectors with actions to scale-up maternal and child nutrition activities. • Develop an advocacy and engagement/training plan for nutrition-sensitive ministries and partners at national and sub-national (gobollada and degmoyinka) levels. • Develop a system to track financing for nutrition by the Somali Federal Government 23 SO 1 Outputs • MSN Strategy launched and disseminated in six events at national and sub- national levels by the national SUN secretariat under the Somalia Office of the Prime Minister (OPM). • Nutrition integrated in all nutrition-sensitive sectors policies and workplans in line with the Multisectoral Nutrition Strategy: A detailed multisectoral nutrition plan with a detailed implementation, financing and M&E plan developed by each state to track progress of results in the common framework. • Sectoral policies reviewed by the Federal and State Governments to ensure they are nutrition-sensitive. • Social Mobilisation, Advocacy and Communication (SMAC) Strategy developed and implemented to support the implementation of this Strategy. • A Financial tracking system for nutrition activities established. SO 1 Indicators • Number of launch/dissemination events for the MSN strategy at national and Sub-national evetns • Number of state-level multi-sectoral nutrition plans developed at National and sub-national levels. • Number of Sectoral*** nutrition policies that are nutrition sensitive (contain at least 3 nutrition actions, with indicators and targets) • Number of sectors with nutrition advocacy plans • Number of relevant sectors trained on nutrition financial tracking tool • Number of nutrition sensitive and specific sector budgets tracked ***Agriculture, Water, Education, Social Protection, Environment, Health***" STRATEGIC OBJECTIVE 2 To create, strengthen and sustain sectoral and Multi-Sectoral Nutrition coordination mechanisms at national and sub-national levels The causes of malnutrition are multisectoral in nature and require a broad range of humanitarian and development actors in different sectors to provide a comprehensive and accountable policy response. The sectors critical for the success of this Strategy include health, education, water and sanitation, agriculture and food security, industry and trade (food availability), women and child development and social protection. This Strategy suggests three practical ways for the Somalia government to ensure that functional and effective coordination mechanisms become a cornerstone of implementing the Strategy. These are: (a) multisectoral coordination must be a priority of the OPM and efforts are be put in place to ensure that conveners have a clear vision of the ‘big picture’ of the role of effective coordination, (b) coordination efforts should be guided by a practical strategy with well-defined roles and responsibilities for participating sectors and agencies with a system for monitoring activities with feedback mechanisms for coordination and overall management and (c) multisectoral nutrition stakeholders must be held responsible for collaboration results. 24 SO 2 Priority Areas 1. Defining Terms of Reference, Accountabilities and Formation of functional multisectoral nutrition coordination mechanisms. 2. To identify coordination of activities in this Strategy as an OPM priority to foster engagement and establish government leadership of multiple agencies and sectors to institutionalise collaboration and coordination processes among donor agencies, government and implementing partners. 3. To establish an effective information system that provides accurate and timely data for evidence-informed planning and implementation, supported by an effective monitoring and evaluation (M&E) framework. SO 2 Interventions • Establish consistent Terms of Reference and Governance structures for multisectoral and multi-stakeholder coordination and management structures and mechanisms at national and sub-national levels. • Formation and strengthening of multi-sectoral coordination mechanisms and networks at national and sub-national levels. • Definition of clear mandates and responsibilities for nutrition stakeholders at different levels. • Building or strengthening the capacity of conveners of multisectoral coordination mechanisms. • Advocating and mobilising financial and human resources for nutrition coordination and partnership activities at all levels. • Organising and documenting regular joint planning and review meetings to align the annual nutrition planning process to the Multisectoral Nutrition Strategy. SO 2 Outputs ● Assigned nutrition focal persons in nutrition-sensitive sector/ministries. ● Functional coordination mechanisms in place by all states; (Undertaking Periodic National and sub-national multisectoral coordination meetings at national and sub-national levels.) ● Capacity of conveners of coordination mechanisms strengthened through bi- annual trainings/workshops. ● A nutrition information system developed for enhanced monitoring and evaluation. ● Prioritized responses to address nutrition and food security related concerns. SO 2 Indicators • Number of nutrition sectors with focal nutrition persons • Number of annual coordination meetings with representation from all nutrition sensitive and specific sectors • Number of annual training/sensitization for a of the conveners, on nutrition coordination • Number of nutrition specific and sensitive sectors submitting timely quarterly reports • Number of policy briefs generated to inform programing/policy change • Proportion of nutrition stakeholders using data and information from the NIMS 25 STRATEGIC OBJECTIVE 3 To improve and strengthen human resource capacity for providing appropriate support to maternal and child nutrition at national and sub- national levels. Increasing the capacity of the human resources for health and nutrition (through increasing the workforce, improving the balance of skills and strengthening capacities) is one of the building blocks of a well-functioning health system highlighted in the Somalia HSSP (and adopted from WHO building blocks of a functional health sector). Although the core of the HSSP Strategy is service delivery that is strongly tied to the implementation of the Essential Package of Health Services (EPHS) in four levels of service delivery (primary health care, health centre, referral health centres and hospital), this Multisectoral Nutrition Strategy goes beyond supporting the HSSP objectives to include the strengthening of capacities in sectors whose inputs can influence nutrition outcomes. This Strategy sets out to develop a nutrition workforce that addresses the priority needs of the Somali population, which is adequate in number, well trained, equitably distributed and motivated to provide essential health services. SO 3 Priority Areas 1. A human resource development strategy in place with a clear and practical action plan. 2. Competencies and training needs for the provision of appropriate support at the different levels identified. 3. Capacity of Federal, State and local governments to provide basic nutrition services is enhanced in an inclusive and equitable manner. 4. Increased availability of skilled health staff and community-based workers delivering basic multisectoral nutrition services at facility and/or community level. 5. Nutrition included in pre-service curricula of training institutes reviewed and updated as per the human resource development strategy. SO 3 Interventions ● Assessment of current size, capacity and training needs in the nutrition workforce including identification of human resource needs and gaps. ● Assess current curricula for nutrition in formal and non-formal education and in pre- and in-service training and make it nutrition-sensitive. ● Stakeholder and capacity mapping of actors in nutrition related sectors for participation in National and sub-national coordination mechanisms. ● Identification of competencies and training needs for coordination mechanisms (technical, management, leadership, coordination, implementation etc.). ● A national and comprehensive capacity development strategy is developed and implemented. ● Development or identification of a training package on nutrition, tailored for different cadre and levels of staff in the Ministry of Health (both pre-service and in-service) and for nutrition-sensitive sectors. 26 ● On-the-job training of various cadres of nutrition in both nutrition-specific and - sensitive sectors. ● Integration of nutrition in the existing curricula of formal and non-formal education and in pre- and in-service training. ● Nutrition-sensitive educational/ training materials developed and disseminated for nutrition-sensitive sectors at all levels (national, State, district, facility). ● Training/capacity building for actors in the multi-stakeholder coordination mechanism strengthening district and sub-district nutrition coordination committees. SO 3 Outputs ● Human resource for nutrition, capacity assessment report developed clearly indicating gaps and plan for achievement of desired targets. (This will include assessment of current nutrition stakeholder-working in other sectors, local and international NGOs,- and the types of services they provide) ● Adequate number and skill set of nutrition workforce planned for, produced and deployed at the right time and place consistent with the findings of a comprehensive human resource assessment and strategy for Somalia. ● Capacity of nutrition coordinating actors at national and sub-national levels is strengthened. SO 3 Indicators • Number of comprehensive nutrition capacity assessments conducted by nutrition sensitive and specific sectors • Number of sectors achieving at least 50% of the prescribed human resource norms and standards for nutritionists • Proportion of new cadre staff received at least one Nutrition training within the first year, in both nutrition-specific and -sensitive sectors • Proportion of National and Sub-national sectors implementing Capacity building strategy • Proportion of existing staff who have received refresher Nutrition training in both nutrition-specific and -sensitive sectors in the past 24 months • Number of curricula revised to include integrated Nutrition topics in formal and non-formal education in pre-service and in-service training • Proportion of District and Sub-district nutrition coordination committees received trainings on coordination in the past 24 months STRATEGIC OBJECTIVE 4 To develop and integrate a full package of nutrition-specific interventions into basic health care services at national and sub-national levels. This objective seeks to improve access to essential nutrition services of acceptable quality through implementation of a core set of nutrition services (covered in the EPHS) to produce the desired outcomes. Achievement of this objective will effectively contribute to the reduction of maternal and child mortality by reducing malnutrition among pregnant women, lactating mothers and children under five years 27 of age through integrating the delivery of nutrition services in the health and other nutrition-sensitive sectors. SO 4 Priority Areas 1. Severely and moderately acutely malnourished children receive appropriate treatment consistent with existing Somalia guidelines. 2. Promotion, protection and support of age-appropriate IYCF practices is provided at facility and community levels. 3. Micronutrient status of children 6-59 months is improved. 4. Micronutrient status of women of reproductive age is improved. 5. Nutrition status of adolescent girls and pregnant and lactating women is improved. 4.1. Priority area 1: Severely and moderately acutely malnourished children receive appropriate treatment consistent with existing Somalia guidelines. Wasting indicates current or acute malnutrition resulting from failure to gain weight or actual weight loss. Causes include inadequate food intake, incorrect feeding practices, disease, and infection or, more frequently, a combination of these factors. Children with severe acute malnutrition (below -3 standard deviations of the median for the reference population) are nine times more likely to die compared to those who are not undernourished (UNICEF/WHO joint statement; identification of SAM, 2009(Horton and Lo, 2013). The graph below shows the odds ratio for mortality in wasted children. Figure 7. Odds ratio for mortality in wasted children. Source: UNICEF/WHO joint statement; identification of SAM, 2009 The Somalia Multisectoral Nutrition Strategy will implement and prioritise curative nutrition actions to rehabilitate severely acutely malnourished children at stabilisation centres (SC) and in outpatient therapeutic programmes (OTP) as a child survival intervention consistent with the Somalia guidelines for the community management acute malnutrition. 28 Outcomes • Reduction in prevalence of acute malnutrition to below WHO emergency thresholds for SAM and MAM. • The performance of the CMAM programme meets the minimum acceptable standards outlined in the national guidelines for community management of acute malnutrition. Interventions Community Management of Acute Malnutrition. Advocate for increased resource allocation for IMAM implementation Outputs 1. Enhanced early case identification. 2. IMAM services reviewed and scaled up Indicators • Proportion of children referred, through community screening • Proportion of children referred through mass screening • Proportion of states meeting sphere standards for IMAM • Proportion of children with acute malnutrition accessing IMAM services • Coverage of IMAM programs nationally and in high burden districts. 4.2. Priority area 2: Promotion, protection and support of age appropriate IYCF practices The Multisectoral Nutrition Strategy recognises that infant and young child feeding practices have the single largest impact on child survival among all preventive health and nutrition interventions. Breastfeeding: The Strategy recognises that breastfeeding, especially six months of exclusive breastfeeding, has a significant effect in the reduction of mortality from the two biggest contributors of infant deaths (diarrhoea and pneumonia) in contexts like Somalia. An infant who is not breastfed is more than 14 times more likely to die than an infant exclusively fed breast milk in the first six months of life (Lancet 2013 pneumonia and diarrhoea series). The Lancet 2013 Pneumonia and Diarrheal Series showed how breastfeeding promotion has a large impact on the reduction of child deaths due to diarrhoea and pneumonia, which are presently the two major direct causes of death in children in Somalia. Complementary feeding: Starting at about six months of life, breast milk alone is insufficient to meet the growing needs of a child. Breast milk must therefore be complemented to fill the gap between the child’s total nutritional needs and the amount provided by breast milk. Outcomes • Reduction in prevalence infant diarrhoea. • Reduction in prevalence of infant pneumonia 29 • Reduction in Infant Mortality Rates. • Reduction in young child morbidity and mortality Interventions ● Appropriate breastfeeding (early initiation, exclusive and prolonged BF) promoted consistently and in accordance with national or sub-national guidelines. ● Promotion of appropriate feeding practices outlined in the National Infant and young Child Feeding Strategies (Somaliland, Puntland and SCZ; 2012- 2016). ● Promotion of exclusive breastfeeding in the first 6 months of life, early initiation of breastfeeding at birth, continued breastfeeding up to 2 years or beyond. ● Adoption and enforcement of The International Code of Marketing of Breastmilk Substitutes at National and Sub-national levels. ● Promotion of adequate and age-appropriate complementary feeding by (a) Combining locally available low-cost foods to create adequate complementary foods; (b) including animal source foods to improve the quality of the diet; (c) promoting home gardening, animal husbandry, and poultry production to increase the availability of high-quality foods at the household level; and (d) using traditional processes to improve the adequacy of plant-based complementary foods (i.e. germination, soaking, fermentation etc.). This outcome is closely linked to SO 5, Priority 1 (nutrition-sensitive agriculture development). ● Access to and utilisation of appropriate WASH practices targeting caregivers and children aged below 5 years (access to potable water, promotion of household water treatment, safe and hygienic food preparation, handwashing with soap at critical times, proper waste and faeces disposal, access and utilisation of latrines, etc.). ● Access to social protection services (e.g. safety net programmes, income generation schemes, homestead food production, small animal husbandry etc.) ● Integration of Early Childhood Development (ECD) activities with existing community- and facility-based nutrition programmes to ensure development and use of locally relevant ECD materials and adoption of appropriate psycho-social care practices. ● Updated/developed and implemented Somalia IYCF Strategy documents and communication materials at national and sub-national levels. ● Use of IYCF media strategy to promote nutrition education to improve caregiver practices through emphasizing on: (a) provision of nutrition information about local foods, (b) promotion of appropriate feeding behaviours on complementary feeding; and (c) use of multiple channels to educate and counsel caregivers (from communication through mass media, individual counselling etc.). ● Nutrition education carried out through an IYCF media strategy that is developed and rolled out; with messaging delivered through mass media, radio, TV, SMS, publications, paper-based advocacy materials ● Sensitization of religious and other community-based organisations to deliver key IYCF messages at district level. 30 Outputs ● Increased proportion of caregivers practicing appropriate feeding practices ● Improved quality, availability and affordability of local complementary foods, and promotion of optimal use of these local foods. ● Increased use of high-quality locally available foods to improve complementary feeding. ● Enhanced policy environment for IYCF ● Enhanced communication for IYCF Indicators ● Exclusive Breastfeeding prevalence ● Proportion of children 6-23 months attaining minimum acceptable diet ● % of health facilities implementing Baby Friendly Hospitals initiative ● Proportion of population aware the international code of marketing for breastmilk substitute at national and sub-national level ● proportion of HHs producing diverse Nutrition food ● Proportion of Households who can afford to purchase local food ● Proportion of children, 6-59 months with access of local complementary food ● Proportion of states where IYCF Strategy is disseminated ● Proportion of mass media stations regularly disseminating IYCF Messaging ● Number of campaigns with IYCF messaging incorporated ● No. of religious leaders and CBOs received sensitization district level 4.3. Priority area 3: Micronutrient status of children 6-59 months improved Like many developing countries, four micronutrient deficiencies viz. Iodine, iron, vitamin A and zinc deficiencies pose the most serious health risk factors among young children and women of reproductive age in the Somalia context. Iron Deficiency Anaemia, IDA, among pregnant women and children under five. Anaemia is a serious public health concern and the most common causes include inadequate dietary intake of iron, malaria and intestinal worm infestations. High prevalence of anaemia among pregnant women and children under five years old is of particular concern not only due to its contribution or association to maternal and child mortality but also due to its substantial health and economic costs, including poor pregnancy outcomes (premature delivery and low birth weight), impaired school performance (due to impaired mental and physical development) and decreased productivity. Vitamin A Deficiency, VAD: Somalia is considered to have vitamin A deficiency as a significant public health problem based on the proxy indicator of the under-five child mortality rate as well as micronutrient survey data (see Situation Analysis section). Vitamin A supplementation is mostly carried out through campaigns associated with vaccination outreach campaigns. Iodine Deficiency Disorders, IDD: Although Iodine deficiency is a leading cause of irreversible mental retardation in children, it is also highly preventable through an effectively implemented universal salt iodisation programme. Insufficient intake of iodine leads to inadequate production of thyroid hormones, causing IDD. Depending on the severity of the deficiency, IDD symptoms include severe and irreversible brain 31 damage to children particularly the foetus, increased risk of still birth, miscarriage and infant death, low birth weight and stunted growth, mental retardation (such as cretinism), goitre, etc. From an economic perspective, even a mild iodine deficiency leads to impairments of perceptual reasoning and could prevent children from attaining their full intellectual potential. The MSN strategic micronutrient control and prevention interventions will include preventive and control of vitamin and mineral deficiencies. Activities will target to reduce vitamin A deficiency, iodine deficiency disorders, iron deficiency and zinc deficiency in the population, to promote the consumption of micronutrient rich foods and to promote public health measures that prevent micronutrient deficiencies Outcomes Improved micronutrient status for children 6-59 months of age. Interventions ● Promote production and consumption of micronutrient rich foods through promotion of a varied and diversified diet. ● Scale up interventions to prevent and control parasitic infestations like hookworm and schistosomiasis (through nutrition-sensitive approaches) e.g. De-worming of children aged 12-59 months through routine health care system and campaigns. ● Effected Public health measures to prevent micronutrient deficiencies (e.g. malaria prevention and control, deworming etc.). ● In appropriate contexts for Somalia, promote consumption of fortified foods that are widely consumed, e.g. promote demand of iodised salt, fortified maize, wheat flour, cooking oils, sugar, etc. ● Micronutrient supplementation through health services and outreach campaigns. ● Use of ORS with zinc to treat diarrhoea. ● Development and implementation of mass food fortification strategy thereby promoting Mass food fortification; Community- and home-based food fortification. ● Starting up of food fortification programmes, focusing initially on universal salt iodisation. ● Strengthening the health system’s ability to provide routine and therapeutic micronutrient supplementation (vitamin A, iron and folic acid supplementation, zinc) for children and women and identified vulnerable groups. Outputs ● Increased consumption of Micronutrient-rich foods by children aged 6-59 months. ● Increased use of therapeutic zinc for treatment of childhood diarrhoea. ● Increased access and utilisation of fortified foods by children aged 6-59 months. 32 ● Increased proportion of Children aged 6-59 months receiving vitamin and micronutrient supplementation in contexts of chronic or acute deficiencies. Indicators ● Proportion of children 6-59 months accessing adequate micro-nutrient intake ● Percentage of children with diarrhoea who receive therapeutic zinc supplementation ● Proportion of children with acceptable Iodine status ● Prevalence of anaemia among children aged 6-59 months of age Proportion of Children aged 6-59 months receiving Bi-annual vitamin A supplementation 4.4. Priority area 4: Micronutrient status of women of reproductive age improved Strategic micronutrient control and prevention interventions targeting women of reproductive age will include prevention and control of vitamin and mineral deficiencies. The strategic interventions include strengthening the health system’s ability to provide routine and therapeutic supplementation (vitamin A, iron and folic acid supplementation, zinc) and promoting consumption of diversified and nutritionally adequate diet across the lifecycle. Outcomes ● Improved micronutrient status for women of reproductive age. Interventions ● Enhance access to micronutrient services for adolescent girls: salt iodisation, school-based annual deworming, home-food fortification, iron and folic acid etc. ● Mass Food fortification. ● Promotion and production and consumption of micronutrient-rich foods. ● Family planning to increase birth spacing. ● Behaviour change communication to prevent traditional practices that affect optimal nutrition e.g. underage marriage (before age of 18 yrs.), taboos that inhibit adequate nutrition etc. ● Integration of the provision of iron and folic acid supplementation into antenatal and neonatal care ● Promoting adequate gestational weight gain. ● Screening of women for anaemia at antenatal and postpartum visits to control and prevent anaemia. ● Strengthen the referral system to manage cases of severe anaemia. ● Cultural practices that inhibit absorption of micronutrients or consumption of nutrient rich foods are addressed. ● Malaria treatment. Outputs 33 • Increased consumption of Micronutrient-rich foods by WRA • Increased access and utilisation of fortified foods by WRA Indicators i. Proportion of households consuming fortified foods (maize and wheat flour, salt, fats/oils) ii. Proportion of children with acceptable Iodine status iii. National food fortification strategy in place 4.5. Priority area 5: Nutrition status of adolescent girls and pregnant and lactating women improved Maternal nutrition: Reaching pregnant women and lactating mothers with effective interventions and programming to improve nutrition and health remains a massive challenge in Somalia where many women and adolescent girls live with the burden of undernutrition caused by hunger and food insecurity, micronutrient deficiencies, energy and protein deficiencies etc. The Strategy targets improvements in the nutrition status of pregnant and lactating women through interventions focused on improving birth outcomes and the future growth and development potential of the unborn child as part of supporting nutrition within the first 1,000 days. The first 1,000 days are critical for the growth and development of the child, from conception to approximately 6 months of age, are equally as important for the infant and young child and is a time when the infant/young child is completely dependent on its mother. As such, the mother’s health and nutritional status plays a key role in the health and nutrition status of the infant/young child. Outcomes Strengthened care practices and services for improved maternal and adolescent girl’s nutrition Interventions ● Provision of comprehensive and routine nutrition assessment counselling and support services (nutrition assessment, promotion of adequate nutrition in ante- and post-natal periods, provision of food supplements etc.) in the community, schools and in health facilities ● Provision of adequate micronutrient services (routine iron and folic acid, multiple micronutrient supplements, iodised salt, deworming). ● Malaria treatment and promotion of utilisation of insecticide treated mosquito nets in malaria endemic areas ● Promote the inclusion of women groups in livelihood and income generation activities. ● Provision of nutrition information about local foods, industrially processed complementary foods, and home fortification of foods. ● Nutrition education about nutrition requirements in pregnancy. 34 ● Provision of nutrition information about local foods, industrially-processed complementary foods, and home fortification of foods. ● Iron and folic acid supplementation. ● Provide comprehensive and routine nutritional assessment and counselling to adolescent girls in. ● Promote girls’ education. ● Promote economic development for out-of-school adolescents through various economic and resilience strengthening opportunities. Outputs ● Increased proportion of adolescent girls, pregnant and nursing mothers with adequate micronutrient intake, through various approaches (supplementation, food based etc.) ● Increased proportion of adolescent girls, pregnant and nursing mothers with education on basic nutrition and dietary diversity and the value of increased nutritional requirements in pregnancy with a particular focus on adolescent girls. ● Monitoring in place on the dietary habits of pregnant women and women of reproductive age in vulnerable populations. ● Increased proportion of adolescent girls, pregnant and nursing mother’s receiving adequate protein and energy intake. Indicators • Proportion of targeted population receiving iron supplementation • Proportion of women of reproductive age with adequate protein-energy intake. • Percentage reduction of adolescent girls aged 15-19 with a BMI <18.5 Percentage reduction of anaemia among pregnant women STRATEGIC OBJECTIVE 5 To improve policy and practises that enhance maternal and child nutritional status through optimal use of nutrition-sensitive services. The 2013 lancet series on maternal and child undernutrition reviewed evidence of nutritional effects of programmes in four sectors: agriculture, social safety nets, early child development and schooling. Some key points on nutrition-sensitive interventions from the series include the following: • Nutrition-sensitive interventions and programmes in agriculture, social safety nets, early child development, and education have enormous potential to enhance the scale and effectiveness of nutrition-specific interventions; improving nutrition can also help nutrition-sensitive programmes achieve their own goals. • Targeted agricultural programmes and social safety nets can have a large role in mitigation of potentially negative effects of global changes and man- made and environmental shocks, in supporting livelihoods, food security, diet quality, and women’s empowerment, and in achieving scale and high coverage of nutritionally at-risk households and individuals. 35 • Evidence of the effectiveness of targeted agricultural programmes on maternal and child nutrition is limited (with the exception of vitamin A); strengthening of nutrition goals and actions and rigorous effectiveness assessments are needed. • Social safety nets are a powerful poverty reduction instrument, but their potential to benefit maternal and child nutrition and development is yet to be unleashed; to do so, programme nutrition goals and interventions and quality of services need to be strengthened. • Combinations of nutrition and early child development interventions can have additive or synergistic effects on child development, and in some cases, nutrition outcomes. Integration of stimulation and nutrition interventions makes sense programmatically and could save cost and enhance benefits for both nutrition and development outcomes. • Maternal depression is an important determinant of sub-optimum caregiving and health-seeking behaviours and is associated with poor nutrition and child development outcomes; interventions to address this problem should be integrated in nutrition-sensitive programmes. • Nutrition-sensitive programmes offer a unique opportunity to reach girls during preconception and possibly to achieve scale, either through school-linked conditions and interventions or home-based programmes. • The nutrition-sensitivity of programmes can be enhanced by: improving targeting; using conditions; integrating strong nutrition goals and actions; and focusing on improving women’s physical and mental health, nutrition, time allocation, and empowerment. SO 5 Priority Areas The key policy priorities under this objective include: 1. To increase the nutrition-sensitivity of agricultural and food security policies, programmes and practices. 2. To ensure that WASH policies, programmes and practices are nutrition- sensitive. 3. To Integrate nutrition into health services to accelerate a reduction in infectious diseases among children under-5 and women of reproductive age. 4. To ensure that social protection programmes identify and support vulnerable households to improve nutrition in the first 1,000 days of life. 5. To improve nutrition-sensitivity of education sector initiatives, especially ECD and education of adolescent girls, through development of clear pathways to improve nutrition outcomes. 6. To strengthen the links between environment, climate change and nutrition. 7. To align SUN multisectoral stakeholders with the Nutrition Plan and Common Results Framework through Public-Private Partnerships. 5.1. Priority area 1: To increase the nutrition-sensitivity of agricultural and food security policies and practices Outcomes 36 Nutrition integrated into Agriculture and Food Security policies, strategies, plans and programs Interventions • Nutrition-sensitive components are included in agriculture policies, strategies, plans and programmes. • Knowledge on nutrition and nutrition-sensitive agriculture is improved among key stakeholders within the agricultural sector. • Context specific nutrition-sensitive training materials are developed for use within the agricultural sector. Outputs • Increased budgetary allocation to nutrition • Improved quality and diversity of household diets in Somalia. • Enhanced post-harvest handling, storage, and utilisation of nutritious foods at the household and farm levels. • Improved food safety at individual, household and community level. • Increased women's decision-making power in agriculture at community and household level. Indicators • Presence of nutrition line in Agriculture Budget • Proportion of policy makers, agricultural officers and extension workers trained on nutrition and nutrition-sensitive agriculture • Proportion of crop and livestock farmers trained on use of modern farming techniques and practices • Proportion of Households with increased production, access to and availability of nutritious food • Proportion of Households who practice proper storage and post-harvest handling Proportion of households with improved food safety scores Proportion of women in decision making power in agriculture at community and Household level 5.2. Priority area 2: To ensure WASH policies, programmes and practices are nutrition-sensitive Outcomes Nutrition integrated into WASH policies, strategies, plans and programs Interventions • Inclusion of nutrition-sensitive components in WASH policies, strategies and plans. • Design and implement nutrition-sensitive WASH programmes are 37 • Nation-wide WASH promotional campaign in place to increase practices on proper hand washing with soap at critical times, especially among adolescents, mothers with infants and young children. • Reinforce and scale up ‘community-led total sanitation’, CLTS, approaches and programmes. • Design and implement community approaches to protect toddlers from exposure to faecal matter. • Development of a Toolkit to guide nutrition-sensitive WASH programming. Outputs • Improved hygiene and sanitation environment at household and community level. • Improved food hygiene practices. Indicators • Proportion of WASH related extension workers trained to deliver nutrition messaging as part of BCC services • WASH related budgets include Nutrition line • Proportion of Households accessing toilets • Proportion of Households access to safe drinking water • Proportion of Households with cooking areas and play areas separate from livestock/ domestic animals and their faeces • Proportion of Households washing hands with soap 5.3. Priority area 3: To integrate nutrition into health services to accelerate a reduction in infectious disease among children under five and women of reproductive age Outcomes Nutrition integrated into Health Services policies, strategies, plans and programs Interventions • Extensive health education and community mobilisation on significance of regular antenatal visits to health facilities by expectant mothers from conception to delivery. • Promotion of ante- and post-natal care services with integrated nutrition support among all pregnant women and lactating mothers. • Assign, train, supervise and support at least one of the health professionals at health unit and health administrative levels (community, district, etc.) to be responsible for organising, implementing and reporting of nutrition activities. • Training of CHWs on integrating nutrition within ANC & PNC. Output • Increased coverage and quality of nutrition-sensitive antenatal and postnatal care delivered by community-based health workers. 38 • A full package of nutrition-specific interventions including management of severe and moderate acute malnutrition is integrated into routine in-patient health and outreach services. • Access to quality primary healthcare (FP, ANC, PNC, IMCI) with integrated nutrition services is increased for children under-5 and women of reproductive age. Indicators • Proportion of women receiving minimum acceptable integrated nutrition and ANC & PNC services. • Proportion of CHWs trained on integrating nutrition with ANC & PNC • Proportion of children aged 6-59 months utilising quality integrated nutrition and primary Health care services . Proportion of women accessing integrated family planning services and nutrition counselling/services Proportion of Community Health workers delivering quality antenatal and postnatal care with integrated nutrition 5.4. Priority area 4: To ensure that social protection programmes identify and support vulnerable households to improve nutrition in the first 1,000 days of life Outcomes Nutrition integrated into Social Protection policies, strategies, plans and programs Interventions • Nutrition-sensitive components are included in social protection policies, strategies, plans and programmes. • Develop and implement programmes for special social assistance and for livelihood promotion and protection in areas with high levels of malnutrition. • Special food-based programmes for vulnerable groups in areas with high malnutrition levels are designed and implemented. Outputs • Functioning social protection system in place providing social transfers and supporting livelihoods for the most vulnerable households and communities. • Linkages between social protection and nutrition sectors put in place. • Knowledge of social protection workers on nutrition and linkages to social protection is increased. Indicators • Proportion of nutritionally vulnerable households receiving social transfers and livelihood support • Social protection related budgets include Nutrition line • Proprotion of social protection policies, strategies and programs that are aligned with clear pathways for improving nutrition in the 1st 1000 days of life 39 • Proporton of special food-based programmes for vulnerable groups in areas with high malnutrition levels designed and implemented • Proportion of social protection training packages with Nutririon component Proprotion of social protection workers trained on Nutrition and linkages on social protection Proportion of Malnutrition cases refered to social protection by Nutrition workers 5.5. Priority area 5: To improve nutrition-sensitivity of education sector initiatives, especially ECD and education of adolescent girls, through development of clear pathways to improve nutrition outcomes. Outcomes Nutrition integrated into Education Sector policies, strategies, plans and programs Interventions • Inclusion of nutrition-sensitive actions in education sector plans. • Strengthen capacity of science teachers in primary and secondary school to support effective implementation of nutrition-sensitive activities in schools. • Advocacy and promotion of school feeding programmes at national and sub-national levels. • Nutrition messaging is integrated into school feeding programmes. • Biannual deworming of all school children. • Iron and Folic Acid, IFA, supplementation initiated for girl students reaching menarche and anaemia status of these students monitored. Outputs • Nutrition status and especially anaemia of adolescent girls enhanced through improved knowledge and practices, from nutrition education at primary and secondary levels. • Nutrition knowledge is increased among education sector staff. • Nutrition services are integrated with ECD services in primary schools. Indicators • Proportion of adolescent girls and boys with basic Nutrition Knowledge Proportion of education staff trained on basic Nutrition Proportion Education sector curriculum(new & revised versions) conforms Nutrition Knowledge 5.6. Priority area 6: To strengthen the links between environment, climate change and nutrition Outcomes Nutrition promoted and linkages enhanced between environment, climate change and nutrition programs Interventions/Activities 40 • Promote the sustainable use and management of the environment for improvement of food and nutrition security. • Conduct an operations research to better understand the links between climate change, temperature, rainfall and agriculture output/livestock production. Output • Practical adaptation measures implemented to reduce nutritional vulnerability of livelihoods in the poorest and most exposed regions. Indicators • No. of operations research conducted on linkage between climate change, temperature, rainfall and agriculture output/livestock production. • No. of campaigns conducted on management of the environment for improvement of food security and nutrition. No. of districts with practical adaptation measures in place to cope with livelihood vulnerability. 5.7. Priority area 7: To align SUN multisectoral stakeholders with the Nutrition Plan and Common Results Framework through public-private partnerships and other arrangements facilitating their participation Outcomes Efficient and effective nutrition governance, coordination and legal frameworks Interventions • Promotion and support to in-country stakeholder networks to organise themselves and participate actively in the implementation of the CRF. • Public and private partners contribute data and utilise a single nutrition information and monitoring framework. • Civil society organisations and private sector stakeholders make programmatic contributions to emergency relief activities to improve nutrition. • Leveraging on the countrywide presence of civil society organisations and the private sector to pass nutrition messaging through provision of entry points for coverage of interventions. • Civil society organisations and private sector actors involved in trade of food products support the nutrition sector's objectives including food fortification, importation of wholesome food products etc. • Civil society organisations and private sector stakeholders are involved in developing resilience strategies. • Civil society organisations and private sector stakeholders are motivated to participate in SUN coordination meetings. • Capacity building and sensitisation to improve effectiveness of public-private partnership in improving nutrition status. Outputs • Enhanced existing nutrition coordination and collaborating mechanisms and linkages between relevant Somali in-country SUN networks effectively organised and participating in the nutrition scaling-up process. 41 • Strengthened partnerships for nutrition • Enhanced nutrition planning and performance monitoring and evaluation • Enhanced multi-sectoral linkages for improved nutrition information efficiencies and cost-effectiveness Indicators • Proportion of private sector actors contributing to emergency relief • Proprotion of releveant private institutions and facilities supporting Nutririon messaging and intervention Proportion of stakeholders utilizing a single Nutrition information and Monitoring framework Proportion of Public and private partners contributing data to central Nutrition information system 42 STRATEGIC OBJECTIVE 6 To address gender and social-cultural factors that hinder improvement of maternal, infant, and young child nutrition at national and sub national level. There are many socio-cultural issues that affect maternal, infant and young child nutrition - and restrictive gender roles in society is a key element of these. The links between mothers’ education and nutrition status of their children are well- established, highlighting that education of girls through secondary level and beyond is a critical intervention for establishing well-nourished households and communities. In addition, delaying first pregnancy beyond the adolescent years is a vital measure for the health and nutrition of girls and young women, as well as their children. Traditional gender roles often dictate that women have little economic empowerment, with limited access to the labour market and minimal control over household income and resources. In such situations, women often cannot make the critical decisions around nutrition and health that are needed for the well-being of the family. Where women’s roles are almost exclusively focused on caring for children and carrying the domestic workload, fathers and men may be excluded from knowledge around appropriate caring practices for their pregnant or breastfeeding wives and the nutritional needs of their young infants and children. As stated in SDG 5, providing women and girls with equal access to education, health care, decent work, and representation in political and economic decision-making processes will fuel sustainable economies and benefit societies. For women to engage more fully in public life and income-generating activities, a shift in the balance of gender roles is needed so that males and other family members adopt some of the domestic and caring roles in support of women. According to the Somali Human Resources for Health Policy, women make up about 42 percent of the health workforce and their active engagement is indispensable to essential lifesaving interventions where they effectively bridge cultural and religious barriers. In most community settings, the healthcare-seeking behaviour of women and mothers is largely determined by the presence or absence of female health workers in the health facilities. Moreover, contrary to the implicit general lower societal prominence of women, the health sector employment confers key social status to women and empowers their families through supportive earning capacities. The female community health workers (marwo caafimaad) concept has been established to extend the limited range of promotive and preventive health services among communities. Female community health workers in Somalia have been important in ensuring access to remote populations, reducing rural-urban discrepancies and improving maternal, reproductive, newborn and child health and nutrition services. The Ministry of Labour and Social Affairs, Ministry of Health, Ministry of Women and Human Rights, Ministry of Education and Ministry of Information will be significantly engaged in leading and delivering on this Strategic Objective, supported by other sectoral line ministries. SO 6 Priority Areas The key policy priorities under this objective include: 43 1. To advocate and seek solutions for reducing workload for all women, especially pregnant women and lactating mothers. 2. To promote economic empowerment and financial inclusion of women 3. To ensure full participation of women in education. 4. To increase women's decision-making power at community and household level 5. To end child marriages and early or child pregnancies. 6. To improve men's understanding of gender issues and their attitudes and behaviour towards women. 7. To increase access to culturally appropriate sexual and reproductive health services. 8. To address detrimental food taboos and norms that impair the nutrition of women, infants, and young children. 9. To ensure that agriculture policy and programmes take account of the different needs of men and women engaged in agriculture and livestock production. SO 6 Interventions • Promotion and support of safe labour-saving technologies at the household and community levels. • Promotion and support of women participation in labour markets • Promotion of Women's participation in education. • Support Women to engage in traditional and formal (political) decision- making structures as active participants. • Support Women's leadership role in the household • Mainstream awareness-raising activities throughout all relevant sectors on effects of child marriage and early pregnancy and use of appropriate approaches for legal provisions and enforcement. • Promotion of male involvement in family health and nutrition programmes • Promotion of male involvement in educational and community gender sensitisation interventions. • Increase availability, access and utilisation of culturally appropriate sexual and reproductive health services. • Reduction of detrimental food taboos and norms that impair the nutrition of women, infants, and young children. • Development of Policies that address the needs of men and women engaged in agriculture and livestock production. SO 6 Outputs • Increased proportion of women making decisions at community and household level • Economically empowered women to enable support of various nutrition related interventions • Reduced child marriages and early child pregnancies • Increased men’s understanding on gender issues • Increased access to culturally appropriate sexual and reproductive health services. SO 6 Indicators • Proportions of women participating in labour markets 44 • Proportion of women in leadership positions at community level • Number of sectors conducting awareness on child marriage and early pregnancy • Girls Gross enrolment ratio Proportion of Health and Nutrition promotion sessions targeting male Proportion of women accessing culturally appropriate reproductive and sexual health services STRATEGIC OBJECTIVE 7 To strengthen organisational, institutional and policy framework for linking humanitarian relief, to recovery and development towards to nutrition improvement at national and sub national level. The concept of Linking Relief, Rehabilitation and Development explores ways to join up short-term life-saving humanitarian interventions and long-term efforts to reduce poverty, vulnerability and malnutrition. It is imperative for humanitarian relief to continue to meet the immediate needs of crises effected populations, including by reducing acute (severe and moderate) malnutrition and mortality. However, it is now widely recognised humanitarian relief needs to be formulated and delivered in ways that strengthen population resilience to future crises, states own capacity for emergency preparedness and response and facilitate the longer-term transition from humanitarian to longer-term development assistance. Development assistance to Somalia has steadily increased since the formation of the Federal Government and agreement of the Somali compact in 2012. However, most of official development assistance to Somalia is still delivered in the form of humanitarian assistance with short-term financial allocations which makes it difficult to apply LRRD in practice. Facilitating the delivery of lifesaving humanitarian assistance in a way that strengthens state institutions and reduces long term population vulnerability to malnutrition is a key aim of this multisectoral nutrition plan. Actions to strengthen institutions and increase populations’ resilience are mainstreamed throughout the plan. However, strategic objective seven explicitly focuses on linking relief, rehabilitation and development efforts to facilitate the transition from a humanitarian to development led approach to addressing malnutrition in Somalia. The following key factors have been identified as of key importance to achieving this aim: • Emergency preparedness and response systems are critical to the timely delivery of cross sectoral interventions in emergencies and they should address multiple population needs and create a synergistic impact on populations’ health and nutrition status. Integration of nutrition throughout systems from surveillance to service delivery and monitoring and evaluation is critical to maximise nutrition impact. 45 • While the Somali Government Ministry of Humanitarian Affairs and Disaster Management and Disaster Management Agency are central focal points for emergency preparedness and response planning, line Ministries also need to integrate nutrition emergency prevention and response plans across sectoral policies, programmes and budgets. • Nutrition information systems are critical to Governments’ emergency response capacity. A well-functioning nutrition information system will utilise a wide range of data sources, including cross sectional data, regular community-based mass screening and sentinel site monitoring, as well as service providers in sectors such as health, education and social protection. • Linking nutrition surveillance systems with wider resilience building measures such as social safety net programmes and livelihood supports has been shown to be an effective way of addressing early onset nutrition emergencies. • To address population vulnerability, disaster management programming needs to be capable of delivering a set of nutrition-specific interventions scalable to meet population needs as well as delivering nutrition-sensitive and resilience building interventions including livelihood diversification and support to agriculture. • Regular market and livelihood analysis allows both governments and partner organisations to assess and respond to changing food security and livelihood situations with targeted and innovative support to livelihoods and address supply-demand market bottlenecks. • Key to integrating nutrition within emergency preparedness and response mechanisms is sensitisation and training for communities and service providers on prevention, mitigation, and response to risks of malnutrition during shocks. • Achieving the transition from emergency interventions to longer-term development cooperation will require strong mobilisation of multilateral and bilateral donors and member States of the Somalia government. SO 7 Priority Areas 1. To integrate nutrition into emergency preparedness plans and protect communities from the impact of shocks and other vulnerabilities that affect nutritional status 2. To put in place a Recovery and Resilience Framework (RRF) that provides the policy, institutional and financial basis to guide the transition from humanitarian relive to recovery to long-term development 3. Priority area 3: To mobilise financing for the transition from emergency interventions to longer-term development 1.1. Priority area 1: To integrate nutrition into emergency preparedness plans and protect communities from the impact of shocks and other vulnerabilities that affect nutritional status Outcomes Improved multi-sectoral capacity for risk preparedness, reduction and mitigation against impact of shocks and other vulnerabilities. Interventions/Activities • Mainstream disaster preparedness and emergency response across all nutrition relevant sectoral policies. 46 • Link early warning systems to nutrition, health and social protection for timely scale up of multisectoral programmes. • Comprehensive package of nutrition services put in place alongside pre- positioning of food items for timely response during emergencies. • Nutrition is integrated across disaster management programmes and activities. Output • Increased access to, and utilisation of, nutrition information for emergency response mechanisms. • Policies and practices of SUN multisectoral platform work to support and implement strategies outlined in the Drought Impact and Needs Assessment (DINA). • Diversified production of drought-resistant crops, including vegetables, and raising of animals tolerant of heat stress at the household and community levels is promoted and supported. • Communities and service providers are sensitised on prevention, mitigation and response to risks of malnutrition during shocks. 1.2. Priority area 2: To put in place a Recovery and Resilience Framework (RRF) that provides the policy, institutional and financial basis to guide the transition from humanitarian relive to recovery to long-term development Interventions/Activities • Market/ livelihood analyses conducted to inform livelihood programmes in different contexts encompassing existing livelihood strategies, coping mechanisms, market demand and financial profitability. • Entrepreneurial activities and livelihood diversification supported particularly for women, people affected by displacement and other vulnerable populations. Outputs • Cross-sectoral programmes are delivered through a targeted approach utilising participatory community-based approaches to help identify populations vulnerable or affected by malnutrition as beneficiaries. • Sustainable livelihoods supported for disaster affected/ vulnerable populations while bridging the emergency relief to rehabilitation transition. 1.3. Priority area 3: To mobilise financing for the transition from emergency interventions to longer-term development Outputs • Multilateral and bilateral donor funds are delivered in line with the New Deal for Fragile and Conflict Affected States. 47 • Increased proportion of multilateral and bilateral donor funds to contribute to actions mitigating the effects of droughts and the avoidance of famine. situations, focusing particularly on internally displaced persons (IDPs), vulnerable pastoralists and riverine and rain-fed farming communities. • Increased proportion of Federal Government and member States to contribute to actions mitigating the effects of droughts and the avoidance of famine. situations, focusing particularly on IDPs, vulnerable pastoralists and riverine and rain-fed farming communities. Indicators • Proportion of Nutrition relevant policies with component of disaster preparedness • Proportion of district with prepositioned Nutrition packages and food items ready for emergencies • Proportion of households with diversified drought resistant crops and heat tolerant animals. • Number of sensitization meetings held on prevention, mitigation and response during shocks No. of districts with integrated Nutrition and disaster management program. Proportion of population accessing Nutrition information through established systems 48 49 ROLLING OUT AND SCALING UP THE STRATEGY Photo credit: Courtesy of Photoshare, 2015 50 4. COORDINATION, ACCOUNTABILITY, SERVICE DELIVERY AND PRIORITISATION Coordination Mechanisms Implementation of the Strategy will commence with consultative meetings with relevant stakeholders under the auspices of the Office of the Prime Minister. The consultations will be convened by the Government Focal Point person for SUN at the Office of the Prime Minister and will; review the Strategy as it applies to the national and State levels; commission the development of a comprehensive road map to achieve results; establish various multisector nutrition coordination platforms and working groups; assign responsibilities of leading and co-leading the various platforms; create mechanisms to assure strong and regular communication between Sub- national and National platforms, track progress and identify and disseminate best practices and lessons learnt, and; define how results will be tracked and monitored, etc. The office of the Prime Minister (OPM) will focus on the overall strategic and operational aspects of implementing the Strategy while relying on relevant ministries (or other agencies as elected) to lead on multisectoral activities such as situational analysis, planning, implementation, assessment, capacity building etc. States will form multi-stakeholder platforms to coordinate the implementation of the common results framework and assign responsibilities to line ministries to coordinate relevant activities, track progress and report results to the Federal Government (Office of the Prime Minister). Agencies and Accountability SUN Movement Focal Point under OPM: Activities in the Strategy will be coordinated by the Office of the Prime Minister. Coordination will entail convening multisectoral coordination forums on an agreed frequency (e.g. inter-agency coordinating committees at national and State level), definition of coordination mandates, receiving progress reports on the implementation of the Strategy, assisting in the identification of best practices and dissemination/implementation in appropriate fora and contexts, monitoring and evaluation of the implementation of the Strategy, facilitating the creation of an enabling environment for the implementation of activities by the stakeholders. Furthermore, the Office of the Prime Minister will be responsible for ensuring inclusive partnerships are developed prior to implementation, that all stakeholders are accountable for results, and that institutional strengthening activities are carried out to support line ministries to carry out their mandates. The OPM will ensure that ‘local’ ownership continues by ensuring that line ministries and other government institutions have sufficient capacity to plan, coordinate and deliver services with respect to their mandates. Multisectoral nutrition coordination platforms and technical working groups: To facilitate effective coordination at both national and state levels, this Strategy recommends the creation of multisectoral nutrition coordination platforms, comprised of key stakeholders from across sectors. These committees will derive their mandates from the Office of the Prime Minister. Conveners will be identified for both National and 51 Sub-national platforms. The committees will work to coordinate activities and serve as platforms to integrate the outputs of various sectors into a coherent national or sub- national programme. They will be responsible for monitoring the progress of implementation of integral or specific aspects of the Strategy, ensuring stakeholders mandates are non-overlapping to avoid duplication of services and assist in holding stakeholders accountable for results. The multisectoral nutrition coordination platforms will, where possible, build upon pre- existing coordination structures in place. For example, the existing Health Advisory Board (comprised of state-level Ministers of Health) and other working groups should be brought together with other relevant stakeholders in establishing multisectoral nutrition coordination platforms. At State level, OPM or particular line ministry, will be tasked with leading and convening coordination activities as appropriate. The multisectoral coordination platforms will be tasked with the formation of multisectoral technical working groups that will be formed to tackle specialised and complex tasks. SUN Movement Networks: The SUN Movement Networks, made up of actors from different stakeholder groups (UN, civil society, donors, business, academic and research), will support the government by participating in multi-stakeholder platforms and aligning their activities behind the foregoing strategic objectives. Business Network: The SUN Business Network will work to find the solutions required to end malnutrition through market-oriented interventions that will build sustainability and local ownership. The business network will support the SUN Movement and ensure compliance with government laws and regulations aimed at protecting, promoting and supporting optimal nutrition for the people of Somalia (e.g. food fortification, the international code for breastmilk substitutes etc.). The business network will support market-oriented strategies that will develop profitable and sustainable food products and business models required to support optimal nutrition among various groups of people in the population. The private sector also has a key role to be explored in the potential for importing fortified foods (especially cereal flours, cooking oils etc.), developing private-public partnerships in the social marketing of micronutrient supplements, to low cost water purification tablets, long lasting insecticide treated bed nets, etc. Civil Society Network: The Civil Society Networks will contribute to operational aspects of implementing non-market-driven aspects of this Strategy to ensure that actions are consistent with Somali government’s policy objectives. National civil society alliances unite diverse organisations, contribute to implementing identified priority interventions, coordinate advocacy and action on nutrition at all levels, ensure government policies and plans reflect the realities and opinions of beneficiaries, ensure rights are realised and strengthen citizen action and inclusion in decision making processes. SUN Donor Network: The SUN Donor Network will be accountable for improving the quality, efficacy and timeliness of aid to maximise its potential impact on nutrition outcomes in Somalia. The SUN donor network has been instrumental in increasing the ownership of the government of Somalia in building sustainable solutions to addressing malnutrition by providing the OPM with the space to set nutrition strategies hereto. The donor network will be responsible to assure that implementing agencies are aligned 52 behind the foregoing nutrition strategic objectives, holding implementing partners and government and to agree to mutual accountability among ‘benefactors and beneficiaries”. The donor network will be critical in assisting in resource mobilisation to translate the strategic objectives into actions and results. UN Network: SUN UN Network for SUN (UNN) is a catalytic force assisting the country to significantly Accelerate the scale-up of their efforts to improve nutrition, ultimately leading to sustainable capacity in nutrition governance and reduced malnutrition. UNN will bring together all UN agencies working in sectors relevant to nutrition to support the government in an efficient, effective and coordinated way. UNN seeks to increase the human and institutional capacities of governments and country stakeholders, in order to foster an enabling environment for nutrition. It focuses on strengthening multisectoral nutrition policies and plans, programme design and implementation, coordination, advocacy, monitoring, evaluation and knowledge management, and ensuring that no one is left behind. Service Delivery Structures for Nutrition-Specific and -Sensitive Interventions The organisational and management structure of the Somali health system comprises of four facility-based health care provision levels collectively aimed at providing optimal coverage of health and nutrition services to the population. Although there is a lack of accurate estimates of the catchment area population for health facilities, it may be approximated that on average Referral health centre (RHC), Health Centre (HC), and primary health care units (PHU) will serve a population of about 100,000; 30,000 and 5,000 respectively. These four levels of service delivery (the fourth being the hospitals, see below), coupled with community-based workers and will be instrumental in delivery of both nutrition-specific and -sensitive interventions. These four levels of service delivery and community workers include: 1. The primary health care units (PHUs) located in the most peripheral geographical areas, covering a defined catchment area population with basic promotive, preventive and simple curative services. The PHU is operated by at least one community health worker (CHW), supported by the local leaders in the organization of health services delivery. The PHU is involved in nutrition promotion and education. 2. Health Centre (HC), operated by qualified nurses and midwives, and nurses particularly trained on EPI and nutrition. Each HC serves the catchment area population of two or more PHUs. A major function of the HC is the provision of basic emergency obstetric care (BEmOC) services supported by a number of delivery beds provided for this purpose. 3. Referral health centre (RHC) or the district hospital. These facilities are expected to provide important referral support functions that include the comprehensive emergency obstetric care (CEmOC) services, implying the availability of appropriate facilities and trained technical staff. The RHC serves the catchment area populations of several health centres. 4. Hospital, which is expected to provide major health care specialty services performed by a number of qualified medical and midlevel health professionals and support staff. 53 Nutrition-sensitive sectors will employ sector-specific delivery structures with activities being integrated with nutrition actors, systems and structures. For example the education sector could use its infrastructure to deliver nutrition interventions (school feeding, deworming, nutrition education targeting adolescents etc.), the education sector could train extension workers to advocate for dietary diversity targeting children from 6 months to 2 years of age, etc. Target Groups and Prioritisation Although the scope of the Strategy will be to improve nutrition outcomes nationally, certain population groups will be prioritised and targeted with evidence-informed strategies and interventions to improve feeding behaviours and nutrition outcomes. This will be in addition to targeting based on age, gender, pregnancy-status etc. outlined in the results section of this Strategy. Targeting by Livelihood Zones Somalia’s diverse livelihood systems can be grouped into four broad categories: pastoralists, agro-pastoralists, fishing/coastal communities and the urban population (Figure 4). The most vulnerable livelihood groups are those that are most affected by shocks caused by floods, drought, displacement, disease, food prices etc. Among these livelihood groups, the riverine and agro-pastoralist groups have traditionally experienced the highest median rate of wasting, stunting and underweight as a result of shocks5 and will be prioritised in service delivery. Pastoralists are mostly nomads tending livestock herds. They are found in all rural areas of Somalia but predominantly in the arid rangelands of northern and central Somalia, as well as along the Ethiopian and Kenyan borders in southern Somalia. They are estimated to have numbered 3.2 million or about 26 percent of the population ((UNFPA 2014, no date). Ninety-nine percent are considered poor across multiple dimensions of poverty and human development (Rogers, no date), World Bank, FAO, 2018. Agro-pastoralists depend on settled crop production and livestock rearing. They are located mainly in the inter-riverine regions of Bay, Bakool, western Hiran, and eastern Gedo in Southern Somalia but also in certain rural areas in southwestern and northwestern Somalia with underground water and high levels of precipitation. A small proportion are riverine crop growers, a small number of whom also have animals on their farms; most keep no livestock. The United Nations Population Fund estimate their number at 2.8 million or about 23 percent of the total population in 2014 (ibid). Duration of Multisectoral Plan This Multisectoral Nutrition Strategy will have a programme cycle duration of 5 years. The timeline is designed to assist in the alignment and harmonisation of government policies. Most government policies and operational strategies hitherto have reached their ‘expiry’ dates and the CRF and Strategy offers a chance of aligning all future and downstream policies and strategies around common objectives and coordination structures. This will improve both policy and operational coherence. 5 Programme document; Toward Millennium Development Goals: Joint Health and Nutrition Programme supporting the Somali Health Sector (JHNP, 2012-16). 54 55 5. OPERATIONAL APPROACHES The following operational approaches will be applied in the implementation of the Multisectoral Nutrition Strategy to contribute to the fulfilment of the vision of the long- term sustainability of the health system and to catalyse the transition of responsibilities of nutrition service delivery to the CHDs and MOH. These operational approaches are designed to help the government and implementing partners to focus on achieving and measuring results. 1. Collaborative Service Delivery Model This Strategy moves away from the traditional model of service delivery followed previous to 2012 where development partners delivered (mostly humanitarian nutrition services) directly through specific primary health care centres without (meaningful) involvement of civil authorities. The multisectoral approach requires a model that shifts away from the humanitarian model to a collaborative approach that offers meaningful participation of all stakeholders in the planning, implementation and monitoring of the multisectoral action plan. 2. Systems Thinking Approach The causal framework for the causes of undernutrition that is employed in this Strategy recognises the various complex multi-level set of causal factors that contribute to the burden of malnutrition in Somalia. A systems thinking approach will be taken to achieving the goals set forth in this Strategy. This will mean taking a non- reductionist approach, allowing space for institutional strengthening, a graduated transference of responsibilities to respective actors and achievement of sustainable results. This will be done through: (a) employing a holistic approach when implementing all components of the Multisectoral Nutrition Strategy, (b) training and identification of systems thinkers and implementers and (c) holding stakeholders accountable for systems thinking approaches. 3. Accountability for Results Stakeholders’ roles in providing support to the achievement of specific results and objectives are outlined within the Common Results Framework which accompanies this document. Individual stakeholders’ responsibilities will be further elucidated within the M&E plans developed to monitor progress towards achieving the objectives and results contained within the Strategy. 4. Accountability for Coordination Effective and collaboration and coordination is an implementation cornerstone of this Strategy. Donors, government and implementing partners should be held accountable for operationalising the mechanisms for coordination outlined in the Strategy and the achievement of shared goals. Stakeholders should build effective and collaborative partnerships and coordination mechanisms that engages local communities, civil authorities, national and international stakeholders and “rights holders”. 5. Rights-based Provision of Services 56 The right of children and mothers to good nutrition and health is the underlying motivation which informs this Strategy and the guides the actions of the Somali Government within the nutrition and health sectors more broadly. Service providers are called upon to provide services as a right to vulnerable populations. Service providers and donors should aspire for a universal and equitable access to acceptable, affordable, cost-effective, and quality nutrition services with maximum impact on Somali population’s nutrition outcomes to ensure the realisation of the right to adequate nutrition and food security. 6. Contextualised Interventions Stakeholders will recognise that a “one size fits all” approach will not work in Somalia. There must be a recognition of the differing contexts within the country so that approaches and interventions can be tailored to suit. For example, stakeholders must be innovative in areas where access is limited and could use existing services and structures as entry points to further strengthening institutions and increasing access to services. 7. Appropriate Technology and Innovative Programming The use of appropriate technology and innovative ways of delivering services is encouraged to accelerate results outlines in this Strategy. It is important to note that innovation is not limited to new technologies, such as mobile telephones or use of the internet; it is more likely to involve approaches applied in other parts of the country, region and world. The key to innovation is therefore to adapt existing, or new, approaches to Somalia’s diverse context. 8. Community Participation in Improving their Nutrition Outcomes Establishing and maintaining the active participation of the community is an important pillar in the implementation of the Somalia Multisectoral Nutrition Strategy. Implementing partners need innovative ways to increase community participation with the aim of increasing the utilisation and demand for health and nutrition services at facility and community level. Community engagement should enable communities to take charge of improving their own nutrition and health outcomes and integrate effective interventions into existing community structures. The use of highly respected community members and community and the religious leaders should be a prime objective to drive robust, effective and sustainable community engagement. 57 6. CAPACITY DEVELOPMENT, ASSESSMENT AND STRATEGY Scaling up the coverage and quality of Somali Government services in nutrition relevant sectors urgently requires addressing the serious human resource capacity constraints the country faces. Due to the high level of humanitarian need and low levels of institutional capacity, nutrition programming in Somalia over the past two and a half decades has tended not to prioritise human resource development. Most service delivery in key nutrition relevant sectors such as health, agriculture, social protection and water and sanitation are still delivered outside the public sector, through private sector, NGOs and UN agencies. Building public sector nutrition capacity in Somalia will require a long-term and multi- pronged approach involving relevant actors from across sectors and tiers, including politicians, ministerial staff, academics and education facilities, front line service providers and communities. To contribute towards achieving this aim, plans are outlined below for, a) a thorough assessment of current nutrition capacity and training needs across sectors and tiers and, b) for the development of a comprehensive nutrition capacity development strategy. Capacity needs assessment While it is known that human resources for nutrition are highly constrained in Somalia, there is currently a lack of data on the number of professionals trained or working in nutrition in the country. This is in part due to the fragmented nature of health service training and delivery which is spread across a range of mostly non-governmental and private sector actors. The first step in addressing nutrition capacity constraints in the country will be the implementation of a nutrition capacity needs assessment including clear definitions of required capabilities and skills. The purpose of this assessment will be to collect data on nutrition-specific actions performed by health workers at different levels within the health care service-delivery system. Data which will be gathered includes the nutrition workforce size, composition, dispersion, accreditation, availability, and gaps, within different levels of the health system including at the facility and community levels. The assessment will follow a number of key steps, the first of which will be identifying government focal persons at the federal and state government levels to lead nutrition workforce mapping activities. These activities should include listing the names of providers of nutrition services, and the types of services they provide and estimates of workforce numbers. Additionally, interviews should be conducted at the national, state, district, facility and community levels to identify existing competencies and gaps. The outcomes of this assessment will be used to inform a national nutrition capacity development strategy. 58 Capacity development strategy To address capacity gaps for delivery of in-patient and out-patient care will require putting in place a comprehensive capacity development strategy. While a focus on health and nutrition-specific activities will be of paramount importance, the strategy will also consider training needs for all categories of civil servants from across relevant sectors and including at the administrative and political levels. Any new strategy will align and complement existing government strategies in the area of health workforce development such as “The Somali Human Resources for Health Development Policy 2016-2021, (Mohamud, 2016)” and the 2015 “Somali Community Health Strategy(Daniels, 2014)” as well the National Development Plan and related sectoral strategies. Wherever possible, existing structures for engaging and training staff will be utilised to avoid duplication and maximise the impact of limited of limited government resources for capacity development. While a focus on addressing immediate workforce capacity constraints is essential, long term organisational and coordination issues will also need to be addressed. The capacity needs assessment and strategy development strategy will also seek to include a strong Monitoring, Evaluation, Accountability and Learning (MEAL) components across sectors and tiers. Capacity development strategy will need to address capacity gaps at several levels At the ministerial and parliamentary levels: It will be necessary to assure actors from different sectors have a common understanding of the key drivers and impacts of malnutrition and how different sectors can contribute to addressing them will be essential. Communicating the theory of change underlying the Common Results Framework and Multisectoral Nutrition Strategy through upcoming launch events and sub-national strategy development will be important first steps in this respect. Engaging actors through the Multi-Stakeholder Platforms, ministerial and parliamentary workshops and trainings can also provide further opportunities for building awareness, understanding and skills. Working with relevant ministries to revise, develop and add to policies as necessary to increase their nutrition impact will also provide additional opportunities towards this end. Identifying nutrition focal points in relevant ministries will be an important part of this cross-ministerial engagement process. Multisectoral platforms: Developing the multisectoral platforms, national and sub- national, will require gauging the set of skills which will be required by participants for active participation, their current capacities and what resources can be leveraged by both governmental and non-governmental partners to strengthen both the technical and strategic capacity of the platforms. Formulation of sub-national nutrition strategies and plan based on the MNS could thus become effective capacity development opportunities if facilitated by well-prepared resource persons Health sector: Capacity development in nutrition will, where possible, be integrated into pre-existing education and in-service training structures for health. Training will be made available for all categories of health worker who can influence nutritional health, including staff such as nurses and community health workers who carry out nutrition related activities. Working closely with private sector providers, NGOs and 59 directly with affected communities will be vital to achieving increased case identification, referral and access to preventative and curative services. To grow the competencies of the nutrition workforce requires, in turn, strengthening the capacity of training institutes, in-service training programmes and monitoring and evaluation systems within the nutrition and wider health sector. During the civil conflict in Somalia, a majority of public sector higher education and training institutions were destroyed, creating an acute shortage of qualified health workers. This led to the proliferation of private medical colleges and health professional training institutions and programmes with little focus on lower and mid-level public health workers or nutritionists. To improve the quality and quantity of skilled nutrition professionals, common competency standards, curricula and accreditation schemes will be developed and harmonised at national and regional levels. The Ministry of Health in cooperation with UN partner organisations are currently undertaking an assessment of academic and vocational training institutions to improve standards and scope of the curricula. National guidelines have been developed on a number of nutrition-specific topics, including Guidelines on Management of Acute Malnutrition and the Somali Treatment Guidelines for the Essential Package of Health Services. Work is underway on the development and updating of national guidelines on a number of other key nutrition topics. Where required, new and existing guidelines may be used for developing teaching modules, for instance, in inpatient and community management of acute malnutrition, nutrition in emergencies and “SMART” nutrition survey training. Sectors outside health: This will require appropriate training across relevant sectors and tiers including policy makers, private sector, NGOs, academics and frontline service delivery staff. Culturally appropriate learning materials will be developed and disseminated for use in sectors such as agriculture, WASH, social protection and education. Materials should draw on best practice and be adapted for use in both education facilities and through “on the job” training. Providing skills in counselling on child feeding practices and dietary diversity, nutrition screening and referral and sector specific nutrition-sensitive actions will be primary areas of focus. 60 7. MONITORING, EVALUATION AND LEARNING 7.1. Introduction The integrated nature of the Multisectoral Nutrition Strategy will need an effective, harmonized and well-coordinated Monitoring and Evaluation (M&E) framework, that assimilates and consolidates results from multiple sectors. This Strategy assumes strong collaboration among stakeholders to enable the development of an effective and shared monitoring, evaluation, accountability and learning (MEAL) framework applicable in the lifecycle of the Strategy. The M&E plan will aim to utilize existing data and information platforms from various sectors as much as possible to avoid duplication. Figure 8, shows the logical framework for monitoring and evaluation of intervention in this strategy. Figure 8: Logical Model for M&E Table 1. Core components of the proposed M&E framework. Monitoring Level Description Key sources of information Proposed frequency Activities Nutrition-specific and -sensitive sector activities that contribute to higher level results in the pyramid. Daily activities: Meetings, trainings Continuous Outputs Programme inputs that have been transformed into outputs Reports, routine data collection platforms, sector level systems including HMIS. Quarterly Outcomes Changes in behaviour and attitudes in the different sectors Survey data, KAP studies, key informers, sectoral data systems e.g. HMIS etc. Annual Impact Changes in the lives of rights- holders through achievement of adequate nutrition outcomes the programme is designed to produce Survey data, KAP studies, key-informers, sector- specific data collection systems etc. Mid- and end-term OUTPUTS OUTCOMES IMPACT INPUTS Planned work Intended results 61 The goal of the M&E Framework: to strengthen monitoring and evaluation in a multisectoral environment for evidence informed decision-making, planning, resource allocation, continued learning and mutual accountability. Objective of the M&E Framework: The main objective is to have a consolidated and harmonized planning, monitoring and evaluation process that informs strategic decision-making. The outputs from the M&E Framework 1. Robust health information systems generating good quality data in a timely manner. 2. Improved efficiency in data generation and management: collection, analysis, dissemination, archiving and public access. 3. Enriched evidence-based nutrition policy dialogue and decision-making. 4. Effective dissemination of nutrition information to stakeholders stimulating action. 5. Strengthened analytical capacity at the different levels of the nutrition system; and 6. Continued learning for better performance, adaptive management in line with evidence Process of implementation of the M&E Framework: It is envisioned that the SUN focal point at the OPM will commission the development of a monitoring and evaluation plan with clear linkages to existing data management systems and milestones for each of the seven strategic objectives. The plan should support the use of standardised methodologies and indicators that are already in use. In the absence of standardised methodologies, it is recommended that validated protocols developed by technical teams be employed. The following support roles to strengthen M&E are envisioned for the Office of the Prime Minister in its role as a SUN convener. • Support policy activities under SO1 that calls for integration of nutrition in other sectors and follow-through to ensure that existing data and information systems capture relevant data and information. • Support the disaggregation of data by sex. • Set clear data and information flow systems with clear timelines and feedback mechanisms. • Ensure data and information is captured in the agreed frequency or timeline (e.g. annual milestones) and reports disseminated in a timely manner to stakeholders. • Ensure a sound validation mechanism for nutrition data and information exists. • Ensure data and information collected is validated by the government prior to dissemination. • Strengthen the routine collection of data for monitoring purposes. • Support stakeholders and lead in the use of data in decision-making. • Provide guidance and leadership in the mid- and end-term evaluations, including efforts aimed at course-correction and learning. 62 7.2. MSN Monitoring i. Data Review processes Data is key for informed decision-making. During monitoring, it is important to prioritize data, and ensure its collection, collation and analysis is well coordinated, with harmonized indicators, all incorporated into the routine management information systems. The figure 9 clearly outlines the possible steps to achieve a coordinated nutrition data review. Figure 9: Nutrition Data Value Chain ii. Performance monitoring These are useful for documenting progress, lessons learnt and measures of success during the implementation of the strategy. A transparent system of multisectoral periodic data and performance reviews involving key nutrition stakeholders will be ensured. All data review, performance monitoring and evaluations processes will produce targeted and actionable recommendations. Nutrition stakeholders will be required to maintain an implementation tracking plan to keep track of review and evaluation recommendations, agreed follow-up actions, and status of these actions. A feedback mechanism should be established to ensure enhanced accountability. Yearly Reviews: A yearly review of progress in the implementation of the seven strategic objectives will offer a snapshot of progress and provide an opportunity for course-correction, identifying lessons learnt and achievements of the year of implementation. Progress and opportunities for each strategic objective will be weighed against the milestones and be employed as tools of accountability for duty- bearers. The CRF and financial tracking tools will be used to show stakeholders the progress made, the challenges faced and what needs to be done. Progress on implementation of the recommendations will need to be tabled at the next annual review. 63 Quarterly Reviews: Quarterly reviews will be done by the specific sectors from routine data collection, Nutrition score cards, and feedback from coordinating structures. During this time, progress is assessed and implementation challenges addressed, thus providing moments for adjustments of activities, before the joint annual reviews. 7.3. MSN Learning Learning will be inbuilt as a continuous aspect in the implementation process of the Multisectoral Nutrition Strategy. It is a critical programme component that should superordinate (and is part of) both monitoring and evaluative processes in the programme cycle. A component of learning willl be embedded in each stage of implementation focusing on learning from both negative and positive experiences. To strengthen and support learning, it will be treated as a crosscutting theme and indicators related to learning developed at both higher and lower levels. The following aspects of programme learning will need to be incorporated in the implementation plans (national and sub-national) • Adaptive management: partners should ensure they use information coming out of collaboration and coordination forums to make better decisions and for course-correction if necessary. Partners should strive to employ intentional approaches to decision-making in response to new information and changes in the implementation context. • Continuous learning: multisectoral coordination forums should ensure that supportive systems and processes are in place. Base continuous learning on asking the right questions and finding practical solutions to enable timely decision-making. • Collaboration with the right partners to promote synergy over stove piping: The coordination mechanism should promote meaningful collaboration among implementing partnerships working on shared goals and (strategic) objectives. • Operational research: to strengthen the overall multisectoral approach and institutionalise the application of research findings into programmes. 7.4. MSN Evaluation Mid Term Evaluation: A mid-term evaluation after 2.5 years will be undertaken to determine the extent to which the objectives of the strategic plan are met, looking at - inputs/processes; outputs; outcomes and impact. It will cover all the targets mentioned in the plan, including targets for outcome and impact indicators. The results will used to adjust strategies, priorities and objectives. End Term Evaluation: The end-term evaluation will be carried out at the end of the strategic period and lessons learnt will be used in the design of the new and follow-on strategy. The main aim of the end term evaluation will be to review final achievements of the nutrition sector against what was planned. It will involve a comprehensive analysis of progress and performance for the whole period of the plan. The various sectors central planning and monitoring departments or equivalent will be responsible for overall oversight of M&E activities at the respective levels. Functional linkage of these sectors will be through the OPM. Evaluation Objectives 64 To test the effect of MSN interventions on the nutrition outcomes suggested, and to examine the implementation experience by the objectives, using a multisectoral approach. Specific Objectives 1. To assess the impact (planned and unplanned) on the various sectors that has resulted from the implementation of MSN. In particular: Capacity building of the communities, counties, and other stakeholders to better address nutrition among populations in the implementation; and coordination of nutrition related interventions. 2. To assess effectiveness of the approaches used by MSN to achieve its overall objective. 3. To determine the extent of accessibility, availability, demand and utilization of nutrition services and nutrition information across the various sectors. 4. To assess the capacity of the health facilities and health workers to provide nutrition information and services. 5. To assess sustainability of interventions in the MSN, for continued promotion of desired nutrition practices and services beyond the implementation period and make necessary recommendations 6. To assess the relevance of MSN in the prevailing country and global nutrition context, and make necessary recommendations for future comparable planning. 7. To understand and document the challenges and best practices during implementation for mutual learning. Evaluation Criteria Clear evaluation questions will guide in carrying out an effective evaluation. b. Effectiveness • Assessment of existing capacity of the various sectors to meet nutrition needs of the community • Assessment of effectiveness of partnership with the various stakeholders in achievement of the overall SMNS objective Assessment of the community strategy structures (Community Health Units) in improving utilization of and accessibility of nutrition services • Assessment of facility based health care providers in utilizing their skills to deliver nutrition services • Assessment of the attitudes and behaviour that have an effect on nutrition outcomes c. Efficiency • Was the process of achieving results efficient? Specifically, did the actual or expected results justify the costs incurred? Were the resources efficiently utilized? • Did MSN activities overlap and duplicate other similar interventions. • Are there more efficient ways and means of delivering more and better results with the available inputs? • Could a different approach have produced better results? • How was MSN collaboration with various stakeholders? 65 • How efficient were the management and accountability structures of MSN? • How did the organizational financial management processes and procedures affect implementation? • What are the strengths, weaknesses, opportunities and threats of the MSN implementation process? d. Sustainability • To what extent are the benefits of the MSN interventions likely to be sustained after the implementation period? • How effective are the exit strategies, and approaches? • Is the country, through the various sectors, committed to the MSN initiatives and likely to support continuation of the initiatives? • What was the working relationship like, with the various sectors and stakeholders, in building their capacity to be able to sustain the gains made by MSN initiatives? • Are there existing challenges that may hinder sustainability of the gains achieved so far? e. Relevance • How relevant were the MSN strategies and interventions to the needs of the various populations. • Were the objectives and strategies realistic, appropriate and adequate to achieve the results? • Are there alternative approaches, which have proved to be more relevant? Evaluation Methodology A mixed methods study approach that combines a quantitative study design with qualitative case studies will be used. 7.5. The common results framework (CRF) For the M&E framework to perform as envisaged, it is critical to develop consensus on a Common Results Framework (CRF). The CRF provides a summary of the objectives, indicators and targets for monitoring progress in implementation. Being a multisectoral strategy, indicators will be drawn from all the sectors involved in nutrition interventions. The Impact Indicators established by the CRF are based on the 2025 WHA nutrition targets. Disaggregation will be by age, gender, education and geographic location. An important aspect in measuring the performance of the MSN is to track regularly and transparently the nutrition investments made through the MSN. This will help in better use of finance data (allocations Vs expenditures), to mobilize increased domestic and external resources for improved nutrition and for purposes of advocacy and better planning. Government investment in nutrition through budgetary allocation to various sectors e.g. health, agriculture, education, WASH, social protection is equally key. Below is a template for the Indicator Matrices. Detailed indicators in the strategy are as seen in annex 2. 66 Objective 1:……………………………………………………………………………………………………… ……….... Output Indicator Baselin e (Sourc e) Mid Term End Term Frequen cy Responsible Output 1.1……… ….. Indicator 1 Indicator 2 Output 1.2……… ….. 67 8. RISK ASSESSMENT, ANALYSIS AND MITIGATION 8.1 Risk identification, assessment and prioritization Risk analysis and management is the systematic use of available information to determine the likelihood of specified events to occur, their magnitude and consequences and how to mitigate them. Risk analysis and management is one of the cornerstones of modern scientific and risk-based approach to planning, and thus its inclusion in the development of the Somalia Multisectoral nutritional strategy. The process facilitates developing options and actions to enhance opportunities and reduce threats to the achievement of objectives. It involves - 1) Risk identification – define risk events and their relationship 2) Risk impact assessment - assessing probability (likelihood) of their occurrence and their consequences (impact). Consequences may include cost, schedule, technical performance, impacts as well as capability or functionality. 3) Risk prioritization analysis: identify risk events from most to least critical. 4) Risk mitigation: The ultimate purpose of risk identification and analysis is to prepare for risk mitigation. Mitigation includes reduction of the likelihood that a risk event will occur and/or reduction of the effect of a risk event if it does occur. The interpretation of risk is based on the likelihood of its occurrence and the level of its consequences/impact. The risk analysis framework can be simplified into a 4x4-table risk assessment matrix, which categorizes risk as simply high, medium or low as in table 2. Table 2: Risk assessment prioritization matrix Likelihood of occurrence Consequence/impact High Medium Low High 5 4 3 Medium 4 3 2 Low 3 2 1 This framework is used together with the SWOT and PESTLE analysis frameworks to develop the “Risk analysis, evaluation and mitigation” matrix for the multisectoral strategy. 8.2 Risk Analysis Frameworks 8.2.1 SWOT Analysis in managing risk The SWOT analysis in the risk assessment and analysis framework considers the strengths, opportunities, weaknesses and threats in relation to the Somalia Multisectoral nutritional strategy implementation(SMNS). Some considerations using this approach would be as follows: • Strengths – What advantages does the SMNS have in addressing malnutrition in somalia? How can they be used effectively to assure good implementation? 68 • Weaknesses – Are there any internal disadvantages in the plan? What should be done to address them? • Opportunities – What are the current external trends which are waiting to be taken advantage of? How should it be done? • Threats – Are there any external factors which may cause a problem and have a negative impact on the plan? Figure 10: SWOT analysis for the SMNS 8.2.2 PESTLE Analysis in managing risk The PESTLE analysis helps categorize the broad areas where the risk analysis can take place. This identification of broad areas is useful when developing a mitigation plan. The broad areas are categorized as follows: • Political – national and global political issues which may have an effect on the SMNS, either immediately or in the future. • Economic – GDP growth, financial allocations to nutrition etc. • Social – The changes in lifestyle and buying trends, media, major events, ethics, advertising and publicity factors. • Technological – Innovations, access to technology, licensing and patents, manufacturing, research funding, global communications. • Legal – Legislation, laws and regulations which have been passed, or proposed and may come into effect and affect smooth implementation of the SMNS. • Environmental – Environmental issues (e.g. climate change) either locally or globally and their impact on nutrition. Strengths 1. Brings all nutrition strategic plans together 2. Plan developed on basis of stakeholder participation and consensus 3 Presence of agreed coordination structures at all levels 4. CRF strengthens tracking of progress on results and finances at a strategic level Weaknesses 1. Coordination and collaboration challenges in multisectoral approches 2. Low human resources capacity 3. Inadequate capacity to produce nutrition commodities 4. Weak Nutrition data for decision making Opportunities 1. Improved Political stability 2. Improved national and global framework for nutrition actions 3. Existing package of high impact interventions 4. high govenment commintment towards the social sector including nutrition interventions Threats 1. Impact of climate change: seasonal droughts and floods 2. Inadequate resources for implementation 3. Changing Political Climate - Volatile security situation and violent insurgency, SWOT ANALYSIS 69 8.3 Risk Mitigation Measures It is anticipated that during implementation of the SMNS various risks may occur which will ultimately hinder effective realization of the aspirations set out in the action plan. The Sector will use a range of risk mitigation options and strategies as shown in table 3. Risk mitigation handling options include: 1) Assume/accept: Acknowledge the existence of a risk and make a deliberate decision to accept it without engaging in special efforts to control it. 2) Avoid: Adjust program requirements or constraints to eliminate or reduce the risk. This adjustment could be accommodated by a change in funding, schedule, or technical requirements. 3) Control: Implement actions to minimize the impact or likelihood of the risk. 4) Transfer: Reassign organizational accountability, responsibility, and authority to another stakeholder willing to accept the risk. 5) Watch/monitor: Monitor the environment for changes that affect the nature and/or the impact of the risk and respond as appropriate. 8.4 Combined risk Analysis, evaluation, prioritization and mitigation measures matrix Table 3 synthesizes the different types of risk analysis frameworks into a single matrix. The PESTLE analysis used to categorize the type of risks; SWOT analysis is used to identify the risk events; the risk analysis framework is used to describe the likelihood of occurrence, their consequences/impact and the risk priority. Lastly the matrix uses the strength and opportunities components of SWOT and other information to propose mitigation strategies and who will be responsible to implement. 70 Table 3: Risk analysis, mitigation and accountability table for the SMNS PESTLE categori zation of risks Identifi ed risk event Risk consequenc e Likelih ood of occurr ence Risk impact /conseq uence Risk prio rity Risk mitigation strategy Respon sibility for mitigati on 1. Political risks 1.Politic al risk • Affect s imple ment ation High High 5 • Develo p and implem ent risk reducti on and emerge ncy conting ency plans includin g for electio ns • Sustain ed Nation al and Subnati onal govern ment engag ement for Nutritio n prioritiz ation • Advoc ate with partner s to maintai n implem entatio 71 PESTLE categori zation of risks Identifi ed risk event Risk consequenc e Likelih ood of occurr ence Risk impact /conseq uence Risk prio rity Risk mitigation strategy Respon sibility for mitigati on n momen tum • Strengt hen Citizen particip ation in deman ding nutrition services 2. Econom ic risks 2. Inadeq uate funding • Some activities slowed or halted • Linkages and relationshi ps disrupted High High 5 • Develo p and implem ent a robust resourc e mobiliz ation strateg y 3. In efficien t mecha nisms for Nutritio n budgeti ng and expend iture monitor ing across sectors and actors • Lost opportuni ties to maximize program me coverage • Impleme ntation cost unknown Mediu m High 3 • Strengt hen Nutritio n sector engag ement at Nation al and subnati onal level in budget ary making process es 72 PESTLE categori zation of risks Identifi ed risk event Risk consequenc e Likelih ood of occurr ence Risk impact /conseq uence Risk prio rity Risk mitigation strategy Respon sibility for mitigati on • Scale up financi al trackin g 4. Weak adhere nce to financi al pledge s and agree ments • Ineffectiv e and inefficient impleme ntation • Lowers credibility and account ability of FNS programs Low Medium 3 • Develo p and strengt hen implem entatio n of partner ship framew orks for the Nutritio n sector 3. Social risks 5. Weak collabo ration by key stakeho lders • Fragment ation and duplicati on in impleme ntation Mediu m High 4 • Strengt hen stakeho lders’ coordin ation platfor ms • Promot e joint plannin g and prioritiz ation, implem entatio n and monitor ing by all 73 PESTLE categori zation of risks Identifi ed risk event Risk consequenc e Likelih ood of occurr ence Risk impact /conseq uence Risk prio rity Risk mitigation strategy Respon sibility for mitigati on stakeho lders 4. Technol ogical risks 6. Inadeq uate infrastru cture and capaci ty to use ICT for M&E and for advoc acy • Inability to achieve high program me efficiency Mediu m Medium 3 • Advoc acy for strategi c investm ent for develo pment and use of ICT for nutrition progra mming. • Enhanc e capaci ty on use of Technol ogy for Nutritio n (T4N) 5. Legal risks 7. Low enforce ment of nutritio n relevan t laws (e.g. food fortifica tion, food safety, marketi ng of BMS, materni • Low compl iance High High 4 • Monitor enforce ment 74 PESTLE categori zation of risks Identifi ed risk event Risk consequenc e Likelih ood of occurr ence Risk impact /conseq uence Risk prio rity Risk mitigation strategy Respon sibility for mitigati on ty leave) 6. Environ mental risks 8. Occurr ence of natural disaster s (e.g. floods, drough t, earthq uake) - ASAL areas. • Disruption of services and access to populatio ns Mediu m High 5 • Monitor and develo p conting ency plans & funding • Mainstr eam sector- wide respons e 8.5 Potential bottlenecks to the implementation of the strategy After two decades of civil war, Somalia faces a range of challenges in its efforts to reduce malnutrition and improve the health and wellbeing of its population. Among the most prominent are: • Somalia has some of the poorest health indicators in the world and some of the lowest levels of access to basic services such as improved water and sanitation and education. • Achieving the goal of this Multisectoral Nutrition Strategy calls for improvements in outcomes across a range of sectors, many of which are starting from a very low level of development. For instance, no Federal Government social protection programme is yet in place while health services are still largely delivered through the private sector and NGOs. • The country also faces severe food insecurity at both the household and macro levels. Food insecurity is in a large part driven by an over-reliance on rain-fed agriculture and livestock production and severe vulnerability to water stress and widespread environmental degradation. • Domestic government funding is limited and reliant on overseas development assistance and remittances with domestic revenues still limited. • The country remains in a volatile security situation and the government continues to face a violent insurgency, concentrated in the countries central and southern regions. Deep clan divisions fuel sporadic inter-clan conflicts while further insecurity is caused by non-state armed groups who continue to have a strong presence in large areas of the country. 75 • Women in Somalia continue to face systematic discrimination and violence. Low levels of access to and participation in education remains a serious impendent to social and economic progress. • Widespread reliance on agriculture and livestock for economic livelihoods hinders diversification and leaves the population vulnerable to climate change and environmental degradation. • These factors continue to contribute to a wide-spread and protracted humanitarian crisis in the country. • Addressing these many challenges in a way which strengthens institutional and governance structures will be vital to maintaining the country’s positive trajectory towards a more prosperous and healthy future for its citizens. 76 BIBLIOGRAPHY (NHD, B. D. (CAH) and A.-B. M. 2008 (no date) Indicators for assessing infant and young child feeding practices PArt 3 Country Profiles. Available at: https://www.unicef.org/nutrition/files/IYCF Indicators part III country profiles.pdf (Accessed: 20 October 2018). Daniels, M. (2014) ‘Somali Community Health Strategy’, (April). Horton, R. and Lo, S. (2013) ‘Nutrition: lancet series on malnutrition 2013’, Lancet (London, England). Elsevier, 382(9890), pp. 371–372. doi: 10.1016/S0140- 6736(13)61100-9. Ingles, A. C., Legare, D. J. and Lautt, W. W. (1994) ‘Health Sector Strategic Plan January 2013 – December 2016’, Can J Physiol Pharmacol, 72(6), pp. 687–692. doi: 10.1139/y94-097. Levitt, E. J., Pelletier, D. L. and Pell, A. N. (2009) ‘Revisiting the UNICEF malnutrition framework to foster agriculture and health sector collaboration to reduce malnutrition: A comparison of stakeholder priorities for action in Afghanistan’, Food Policy. Pergamon, 34(2), pp. 156–165. doi: 10.1016/J.FOODPOL.2008.07.004. MOH-FGS/UNICEF (no date) ‘Basic Nutrition Services Package Final’. MoH-SNS; 2011-2013 (no date) SOMALI NUTRITION STRATEGY 2011-2013 Towards the Millennium Development Goals. Available at: https://extranet.who.int/nutrition/gina/sites/default/files/SOM 2010 Nutrition Strategy.pdf (Accessed: 20 October 2018). Mohamud, D. K. B. (2016) ‘The Somali Human Resources for Health Development Policy’. Pearson, N. and Muschell, J. (2009) HealtH ServiceS eSSential Package of Somalia. Available at: https://www.unicef.org/somalia/SOM EssentialpackageReport 2- WEB.pdf (Accessed: 20 October 2018). PLAN, N. D. and 2019, 2017 - (2016) ‘Federal Government of Somalia’, 234(12), pp. 1– 48. Available at: http://mopic.gov.so/wp-content/uploads/2016/12/Smalia-National- Development-Plan-2017-2019Final14Dec.pdf. Puntland, M. (2012) Infant and Young Child Feeding Strategy for Puntland Ministry of Health Garowe-Puntland Produced with support from UNICEF. Available at: https://extranet.who.int/nutrition/gina/sites/default/files/SOM IYCF Strategy and Action Plan for Puntland 2012-2016.pdf (Accessed: 20 October 2018). Rogers, D. F. and H. (no date) ‘Multiple dimensions of poverty and human development (World Bank, FAO, 2018)’. doi: 10.1596/978-1-4648-1096-1. SMS, F. I. C. on N. in 1992. (2016) ‘SOMALI NATIONAL MICRONUTRIENT DEFICIENCY CONTROL STRATEGY’. Somaliland, M. (2012) National Infant and young Child Feeding Strategy for Somaliland Ministry of Health Republic of Somaliland Produced with support from 77 UNICEF 2. Available at: https://extranet.who.int/nutrition/gina/sites/default/files/SOM National IYCF Strategy and Action Plan for Somaliland 2012-2016.pdf (Accessed: 20 October 2018). Strategy, I. and Plan Somalia, A. (2013) IYCF Strategy and Action Plan for South Central Somalia. Available at: https://extranet.who.int/nutrition/gina/sites/default/files/SOM IYCF Strategy and Action Plan for SCZ FINAL Nov 2012.pdf (Accessed: 20 October 2018). Sultan Amri MOA, F. (2016) ‘Agriculture Strategic Plan 2016-2020’, (April). UNFPA 2014, P. (no date) 2014 UNFPA population estimation, district information released | Somali Spot | Forum, News, Videos. Available at: https://www.somalispot.com/threads/2014-unfpa-population-estimation-district- information-released.9350/ (Accessed: 19 October 2018). WHO-Somalia (2014) ‘Prioritization of Health Policy Actions in Somali Health Sector’, World Health Organization, Somalia, (September). Available at: http://www.mohpuntland.com/wp-content/uploads/2016/03/FINAL- Somali Health Policy Directions and Priorities-Dec-2014-2.pdf. 78 ANNEXES 79 ANNEXES ANNEX 1: METHODS The Somalia Common Results Framework was developed through wide consultation processes, involving a broad range of key stakeholders including the Somali line ministries and stakeholders in both nutrition-specific and -sensitive sectors, United Nations agencies (WHO, UNICEF and UNFPA), development partners, civil society organizations and the Somalia emergency nutrition cluster. Consultations were carried out in Nairobi by the team leader, Haron Maina Muthee, and in Somalia by the local consultant, Ahmed Siyad. Feedback and output from these consultations was used to stitch the common results narrative to ensure context-appropriateness. The narratives for the Multisectoral Nutrition Strategy was spawned from the common results framework. The Strategy was developed by the team leader, Haron Maina Muthee, assisted by a team of consultants including Tamsin Walters, Christopher Coffey, Ahmed Siyad and Job Gichuki. The Strategy document was sent to an external reviewer hired by MQSUN+ and to major stakeholders located in Nairobi and Mogadishu (including UN agencies, civil society, Office of the Somalia Prime Minister, nutrition-sensitive line ministries, ministry of health etc.) Both the Multisectoral Nutrition Strategy and Common Results Framework were underscored by a situation appraisal that was developed by a consultant, Christopher Coffey, using a desk review approach. After incorporation of feedback from stakeholders, the Multisectoral Nutrition Strategy and Common Results Framework were once again presented to key stakeholders in a validation workshop held in Nairobi, Kenya, and convened by the Somalia Office of the Prime Minister. This workshop collected valuable insights that were again incorporated into the document prior to a formal endorsement by the Somalia government. 80 ANNEX 2: COMMON RESULTS FRAMEWORK STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) To create an enabling policy and legal environme nt necessary for improvem ent of nutrition outcomes across all the sectors both at national and sub national level. MSN Strategy launched and disseminated at national and sub-national levels Number of launch/disseminati on events for the MSN strategy at national and Sub- national events 0 6 6 CRF Launch Report, Participant list and Photos OPM and President of the Federal Member States Nutrition integrated in all nutrition- sensitive sectors policies and workplans in line with the Multisectoral Nutrition Strategy Number of state- level multi-sectoral nutrition plans developed at National and sub- national levels. 0 3 6 OPM(SUN Office), Social Sector Line Ministries, Nutrition/H ealth Cluster Partners. Sectoral policies reviewed by the Federal and State Governments to ensure they are nutrition- sensitive. Number of Sectoral nutrition policies that are nutrition sensitive (contain at least 3 nutrition actions, with indicators and targets) ***Agriculture, Water, Education, Social Protection, Environment, Health*** 0 3 6 Consultatio n/Planning session minutes, List of Participants and Validated Multi- sectoral Nutrition Plans OPM(SUN Office), Social Sector Line Ministries, Nutrition/H ealth Cluster Partners. Social Mobilisation, Advocacy and Communication (SMAC) Strategy developed and implemented Number of sectors with nutrition advocacy plans 0 3 6 Updated sectoral Policies, Consultatio n reports and List of stakeholder s engaged in the process OPM(SUN Office), Social Sector Line Ministries, Nutrition/H ealth Cluster Partners. A Financial tracking system (FTS) for nutrition Number of relevant sectors trained on nutrition financial tracking tool 0 2 6 Training reports OPM(SUN Office), Social Sector Line 81 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) activities established. Ministries, Nutrition/H ealth Cluster Partners. Number of nutrition sensitive and specific sectors using FTS to track funding for nutrition. 0 2 6 Capacity assessment reports OPM(SUN Office), Social Sector Line Ministries, Nutrition/H ealth Cluster Partners. To create, strength en and sustain sectoral and Multi- Sectora l Nutritio n coordin ation mecha nisms at nationa l and sub- nationa l levels. Assigned nutrition focal persons in nutrition- sensitive sector/ministries. Number of nutrition sectors with focal nutrition persons 0 4 6 Assessment reports OPM(SUN Office), Social Sector Line Ministries, Nutrition/H ealth Cluster Partners Functional coordination mechanisms in place Number of coordination meetingsheld with representation from all nutrition sensitive and specific sectors 0 10 20 Identificatio n criteria, list of conveners OPM(SUN Office), and SUN Regional focal points, Nutrition and Health Cluster Capacity of conveners of the nutrition coordination team strengthened Number of training/sensitizatio n for a of the conveners, on nutrition coordination 0 5 10 Guidance tools, Disseminati on Plan and Reports SUN office, M.O.H and H/Nutrition Cluster A nutrition information system developed for enhanced monitoring and evaluation. Number of nutrition specific and sensitive sectors submitting timely quarterly reports 0 4 6 Reports/me eting minutes Social Sectoral Line Ministries, SUN regional focal 82 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) Offices and SUN Country office. Prioritized responses to address nutrition and food security related concerns. Number of policy briefs generated to inform programing/policy change 0 20 40 Program reports Social Sectoral Line Ministries, SUN regional focal Offices and SUN Country office. Proportion of nutrition stakeholders using data and information from the NIMS 0% 30% 60% Program reports Social Sectoral Line Minsitries, SUN regional focal Offices and SUN Country office. To improv e and strength en human resourc e capacit Human resource for nutrition, capacity assessment report developed clearly indicating gaps and plan for achievement of desired targets. Number of comprehensive nutrition capacity assessments conducted by nutrition sensitive and specific sectors 0 2 6 Assessment report, Participant list OPM(SUN Office), Federal Member states, MoE, M.O. H, Ministry of Planning and Nutrition Cluster 83 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) y for providin g approp riate support to matern al and child nutrition at nationa l and sub- nationa l levels. Adequate number and skill set of nutrition workforce planned for, produced and deployed at the right time and place consistent with the findings of a comprehensive human resource assessment and strategy for Somalia. Number of sectors achieving at least 50% of the prescribed human resource norms and standards for nutritionists No dat a 3 6 Assessment report, Participant list OPM(SUN Office), Federal Member states, MoE, M.O. H, Ministry of Planning and Nutrition Cluster Improved technical capacity for clinical nutrition and dietetics Proportion of new cadre staff received at least one Nutrition training within the first year, in both nutrition-specific and -sensitive sectors 0% 50% 70% Training reports M.O.H, Nutrition Cluster and SUN Office Proportion of National and Sub- national sectorts implementing Capacity building strategy 0% 35% 70% Sectoral Capcity Building reports OPM(SUN Office), and Social sectro Ministries Proportion of existing staff who have received refresher Nutrition training in both nutrition-specific and -sensitive sectors in the past 24 months 0% 35% 50% Training reports, Attendance list, Photos M.O.H, Nutrition Cluster Partners and SUN Office 84 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) Number of curricula revised to include integrated Nutrition topics in formal and non-formal education in pre- service and in- service training 0 2 4 Revised Curricula MoE, M.O.H and SUN office Capacity of nutrition coordinating actors at national and sub-national levels is strengthened. Proportion of District and Sub- district nutrition coordination committees received trainings on coordination in the past 24 months 0% 50% 100 % Training reports, Attendance list and Photos. M.O.H, MoE and federal Member states To develo p and integrat e a full packag e of nutrition - specific interven tions into basic health care services at nationa Priority area 1: Severely and moderately acutely malnourished children receive appropriate treatment consistent with existing Somalia guidelines. Enhanced early case identification Proportion of children referred, through community screening 0% 40% 70% Screening reports, referral and screening data M.O.H and Nutrition Cluster Partners Proportion of children referred through mass screening 0% 15% 25% Screening reports, referral and screening data M.O.H and Nutrition Cluster Partners Proportion of states meeting sphere standards for IMAM No dat a 40% 60% Report M.O.H and Nutrition Cluster Partners 85 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) l and sub- nationa l levels. IMAM services reviewed and scaled up Proportion of children with acute malnutrition accessing IMAM services No dat a 40% 60% Assessment Reports M.O.H, Ministry of Water and Energy, Nutrition cluster partners Coverage of IMAM programs nationally and in high burden districts. Nati onal med ian/ mea n Not Avai labl e 35% Rural >50% Urba n >70% IDP 50% Rur al >70 % Urb an >90 % IDP Routine program data, SQUEAC report M.O.H, Ministry of Water and Energy, Nutrition cluster partners Proportion of practising nutrition staff trained on CMAM 67% 80% 90% Training reports, surveys, Photos and attendance list SUN Office, M.O.H and Nutrition Cluster Partners Priority area 2: Promotion, protection and support of age appropriate IYCF practices Increased proportion of caregivers practicing appropriate feeding practices Exclusive Breastfeeding prevalence 33% 42% 50% IYCF program routine data ; survey data all sectors at National and sub- national level Proportion of children 6-23 months attaining minimum acceptable diet 0% 35% 50% Survey data, routine program data M.O.H and Health Cluster Partners Percentage of health facilities implementing Baby Friendly Hospitals initiative 0% 30% 50% facility reports and surveys MOH Data M.O.H and Health Cluster Partners Improved quality, availability and affordability of Proportion of population aware the international code of marketing 0% 30% 50% survey data all sectors at National and sub- 86 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) local complementary foods, and promotion of optimal use of these local foods. for breastmail substitute at national and sub- national level national level proportion of HHs producing diverse Nutrition food 0% 30% 60% Market reports, Surveys Ministry of Agriculture Proportion of Households who can afford to purchase local food 0% 30% 60% Market reports, Surveys Ministry of Agriculture Increased use of high-quality locally available foods to improve complementary feeding. Proportion of children, 6-59 months with access of local complementary food 0% 30% 60% Survey reports Ministry of Agriculture Enhanced policy environment for IYCF Proportion of states where IYCF Strategy is disseminated 0% 80% 100 % IYCF Media strategy Document Ministry of Information , M.O.H Enhanced communication for IYCF Proportion of mass media stations regularly disseminating IYCF Messaging 0% 50% 80% Monitoring Data and Surveys Ministry of Information , Culture & Tourism, M.O.H and SUN Office Number of campaigns with IYCF messaging incorporated 0 2 6 Campaign plans, reports and photos Ministry of Information , M.O.H No. of religious leaders and CBOs received sensitization district level 0 500 139 5 Reports, Surveys Communit y religious leaders, M.O.H, MoE and Nutrition Cluster Partners Priority area 3: Micronutrient status of children 6-59 months improved 87 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) Increased consumption of Micronutrient- rich foods by children aged 6-59 months. Proportion of children 6-59 months accessing adequate micro- nutrient intake No dat a No data No dat a Survey and facility level data reports M.O.H and Health Cluster partners Increased use of therapeutic zinc for treatment of childhood diarrhoea. Percentage of children with diarrhoea who receive therapeutic zinc supplementation No dat a 60% 80% Survey and facility level data reports M.O.H and Health Cluster partners Increased access and utilisation of fortified foods by children aged 6-59 months. Proportion of children with acceptable Iodine status 0% 60% 80% Micro- nutrient survey reports M.O.H and Health Cluster partners Increased proportion of Children aged 6-59 months receiving vitamin and micronutrient supplementatio n in contexts of chronic or acute deficiencies. Prevalence of anaemia among children aged 6-59 months of age 59% 40% 30% Micro- nutrient survey reports M.O.H, Health Cluster partners Proportion of Children aged 6-59 months receiving Bi-annual vitamin A supplementation No dat a 40% 70% Survey and facility level data reports M.O.H and Health Cluster partners Deworming Coverage 25% 40% 55% Survey report M.O.H and Health Cluster partners Priority area 4: Micronutrient status of women of reproductive age improved Increased consumption of Micronutrient- rich foods by WRA Proportion of households consuming fortified foods (maize and No dat a No data No dat a Micro- nutrient survey reports M.O.H and Health Cluster partners 88 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) wheat flour, salt, fats/oils) Increased access and utilisation of fortified foods by WRA Proportion of children with acceptable Iodine status 0% 60% 80% Micro- nutrient survey reports M.O.H and Health Cluster partners National food fortification strategy in place NO YES YES Strategy document Social sector ministries at National and Sub- national level Priority area 5: Nutrition status of adolescent girls and pregnant and lactating women improved Increased proportion of adolescent girls, pregnant and nursing mothers with adequate micronutrient intake Proportion of targeted population receiving iron supplementation No dat a 50% 80% Household based survey and assessment reports M.O.H, Health Cluster partners Increased proportion of adolescent girls, pregnant and nursing mothers with education on basic nutrition and dietary diversity and the value of increased nutritional requirements in pregnancy with a particular focus on adolescent girls. Proportion of women of reproductive age with adequate protein-energy intake. No dat a 40% 75% Household based survey and assessment reports M.O.H, Health Cluster partners Monitoring in place on the dietary habits of pregnant women and Percentage reduction of adolescent girls aged 15-19 with a BMI <18.5 No dat a 5% 10% Household based survey and assessment reports M.O.H, Health Cluster partners 89 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) women of reproductive age in vulnerable populations. Increased proportion of adolescent girls, pregnant and nursing mother’s receiving adequate protein and energy intake. Percentage reduction of anaemia among pregnant women No dat a 5% 10% Household based survey and assessment reports M.O.H, Health Cluster partners To improv e policy and practise s that enhanc e matern al and child nutrition al status through optimal use of nutrition - sensitiv e services . Priority area 1: To increase the nutrition-sensitivity of agricultural and food security policies and practices Increased budgetary allocation to nutrition Presence of nutrition line in Agriculture Budget NO YES YES Financial reports and budgets Ministry of Agriculture, finance and MOP Ministry Improved quality and diversity of household diets in Somalia. Proportion of policy makers, agricultural officers and extension workers trained on nutrition and nutrition-sensitive agriculture 0% 40% 80% Training report, participant list, survey Ministry of Agriculture and M.O.H Proprotion of crop and livestock farmers trained on use of modern farming techniques and practices 0% 40% 80% Training report, participant list, survey Ministry of Livestock, Agriculture and M.O.H Proportion of Households with increased production, access to and availability of nutritious food 10% 25% 40% program reports and surveys Ministry of Agriculture and Minstry of trade 90 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) Enhanced post- harvest handling, storage, and utilisation of nutritious foods at the household and farm levels. Proportion of Households who practice proper storage and post- harvest handling 0% 30% 60% Surveys, field visit reports Ministry of Agriculture Improved food safety at individual, household and community level. Proportion of households with improved food safety scores No Dat a 15% 40% Assessemnt reports Ministry of Agriculture Increased women's decision-making power in agriculture at community and household level. Proportion of women in decision making power in agriculture at community and Household level 0% 10% 25% program reports and surveys Ministry of Agriculture Priority area 2: To ensure WASH policies, programmes and practices are nutrition- sensitive Improved hygiene and sanitation environment at household and community level. Proportion of WASH related extension workers trained to deliver nutrition messaging as part of BCC services 0% 40% 60% Training reports, Photos, attendance list Ministry of Water and Energy and WASH Cluster WASH related budgets include Nutrition line NO YES YES Budgets and Financial reports Ministry of Water and Finance and Planning Ministries Proportion of Households accessing toilets No Dat a 40% 70% WASH KAP survey Reports Ministry of Water and Energy and WASH Cluster Proportion of Households access to safe drinking water No Dat a 50% 70% WASH KAP survey Reports Ministry of Water and Energy and 91 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) WASH Cluster Proportion of Households with cooking areas and play areas separate from livestock/ domestic animals and their faeces No Dat a 40% 60% WASH KAP survey Reports, field visit reports. Ministry of Livestock and M.O.H Improved food hygiene practices. Proportion of Households washing hands with soap No Dat a 40% 60% WASH KAP survey Reports, field visit reports. M.O.H Priority area 3: To integrate nutrition into health services to accelerate a reduction in infectious disease among children under five and women of reproductive age Increased coverage and quality of nutrition- sensitive antenatal and postnatal care delivered by community- based health workers. Proportion of women receiving minimum acceptable integrated nutrition and ANC & PNC services. No dat a 50% 80% Health facility reports and KAP Surveys M.O.H, Health cluster partners Proportion of CHWs trained on integrating nutrition with ANC & PNC No dat a 40% 50% Training reports, Photos, attendance list M.O.H, Health cluster partners A full package of nutrition- specific interventions including management of severe and moderate acute malnutrition is integrated into routine in- patient health and outreach services. Proportion of children aged 6-59 months utilising quality integrated nutrition and primary Health care services . No dat a 40% 60% Health faciltiy reports and KAP Surveys M.O.H, Health cluster partners 92 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) Access to quality primary healthcare (FP, ANC, PNC, IMCI) with integrated nutrition services is increased for children under-5 and women of reproductive age. Proportion of women accessing integrated family planning services and nutrition counselling/services No dat a 40% 60% Health faciltiy reports and KAP Surveys M.O.H, Health cluster partners Proportion of Community Health workers delivering quality antenatal and postnatal care with integrated nutrition 0% 70% Surveys, field visit reports M.O.H, Health cluster partners Priority area 4: To ensure that social protection programmes identify and support vulnerable households to improve nutrition in the first 1,000 days of life Functioning social protection system in place providing social transfers and supporting livelihoods for the most vulnerable households and communities. Proportion of nutritionally vulnerable households receiving social transfers and livelihood support 0% 40% 70% Quarrterly reports and surveys sectoral line ministries of Nationa and sub- nationaal level Social protection related budgets include Nutrition line 0 1 1 Financial reporting documents and budgets sectoral line ministries of Nationa and sub- nationaal level Linkages between social protection and nutrition sectors put in place. Proprotion of social protection policies, strategies and programs that are aligned with clear pathways for improving nutrition in the 1st 1000 days of life 0% 50% 70% Policy, strategy and planning documents sectoral line ministries of Nationa and sub- nationaal level Proportion of special food-based programmes for vulnerable groups in areas with high malnutrition levels No Dat a 40% 60% Quarrterly reports and surveys Ministry of Agriculture 93 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) designed and implemented Knowledge of social protection workers on nutrition and linkages to social protection is increased. Proportion of social protection training packages with Nutririon component No Dat a 30% 50% Training packages M.O.H and Ministry of Women and Human Rights Proportion of social protection workers trained on Nutrition and linkages on social protection No Dat a 30% 50% Training reports, Photos, attendance list Proportion of Malnutrition cases referred to social protection by Nutrition workers No Dat a 40% 60% Referral documents, Quarterly reports and HMIS Data M.O.H and Ministry of Women and Human Rights Priority area 5: To improve nutrition-sensitivity of education sector initiatives, especially ECD and education of adolescent girls, through development of clear pathways to improve nutrition outcomes. Nutrition status and especially anaemia of adolescent girls enhanced through improved knowledge and practices, from nutrition education at primary and secondary levels. Proportion of adolescent girls and boys with basic Nutrition Knowledge 0% 60% 80% Surveys, field visit reports sectoral line ministries of National and sub- national level Nutrition knowledge is increased among education sector staff. Proportion of education staff trained on basic Nutrition 0% 40% 65% Training reports, Photos, attendance list MoE and M.O.H 94 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) Nutrition services are integrated with ECD services in primary schools. Proportion Education sector curriculum(new & revised versions) conforms Nutrition Knowledge 0% 70% 90% New and revised Curriculum sectoral line ministries of National and sub- national level Priority area 6: To strengthen the links between environment, climate change and nutrition Practical adaptation measures implemented to reduce nutritional vulnerability of livelihoods in the poorest and most exposed regions. No. of 0perations research conducted on linkage between climate change, temperature, rainfall and agriculture output/livestock production. 0 2 6 Research Concepts and reports Sectoral line ministries of National and sub- national level No. of campaigns conducted on management of the environment for improvement of food security and nutrition. 0 80 180 Research Concepts and reports Sectoral line ministries of National and sub- national level No. of districts with practical adaptation measures in place to cope with livelihood vulnerability. 0 20 50 Research Concepts and reports Sectoral line ministries of National and sub- national level Priority area 7: To align SUN multisectoral stakeholders with the Nutrition Plan and Common Results Framework through public-private partnerships and other arrangements facilitating their participation Enhanced existing nutrition coordination and collaborating mechanisms and linkages between relevant Somali in-country SUN Proportion of private sector actors contributing to emergency relief 0% 30% 60% Emergency coordinatio n minutes reports Ministry of Industry and Commerc eand Ministy of Humanitari an 95 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) networks effectively organised and participating in the nutrition scaling-up process. Strengthened partnerships for nutrition Proportion of relevant private institutions and facilities supporting Nutrition messaging and intervention 0% 50% 70% Surveys Ministry of Industry and Commerc e and Ministry of information Enhanced nutrition planning and performance monitoring and evaluation Proportion of stakeholders utilizing a single Nutrition information and Monitoring framework 0% 30% 50% HMIS database Sectoral line ministries of National and sub- national level Enhanced multi- sectoral linkages for improved nutrition information efficiencies and cost- effectiveness Proportion of Public and private partners contributing data to central Nutrition information system 0% 40% 60% HMIS database Sectoral line ministries of National and sub- national level To address gender and social- cultural factors that hinder improv Increased proportion of women making decisions at community and household level Proportions of women participating in labour markets No dat a 20% 60% Market Survey reports Ministry of women and Human Rights Proportion of women in leadership positions at community level No dat a 30% 50% Survey reports Sectoral line ministries of National and sub- national level 96 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) ement of matern al, infant, and young child nutrition at nationa l and sub nationa l level. Economically empowered women to enable support of various nutrition related interventions Number of sectors conducting awareness on child marriage and early pregnancy 0 5 10 Surveys, sector reports MoE, Ministry of women and Human Rights Reduced child marriages and early child pregnancies Girls Gross enrolment ratio 20% 30% 40% Education surveys Increased men’s understanding on gender issues Proportion of Health and Nutrition promotion sessions targeting male No dat a 15% 30% Promotion plans and reports Sectoral line ministries of National and sub- national level Increased access to culturally appropriate sexual and reproductive health services. Proportion of women accessing culturally appropriate reproductive and sexual health services No dat a 40% 75% HMIS data, Surveys M.O.H To strength en organis ational, institutio nal and policy framew ork for linking Policies and practices of SUN multisectoral platform work to support and implement strategies outlined in the Drought Impact and Needs Assessment (DINA). Proportion of Nutrition relevant policies with component of disaster preparedness No dat a 40% 60% Sectoral policies Sectoral line ministries of National and sub- national level Proportion of district with prepositioned Nutrition packages and food items ready for emergencies No dat a 20% 50% Surveys, field visit reports Sectoral line ministries of National and sub- national level 97 STRATEGIC OBJECTIVE S OUTPUTS INDICATORS Bas elin e (201 9) Targets Means of Verification Support Mid term (2022 ) End ter m (20 24) humani tarian relief, to recover y and develo pment towards to nutrition improv ement at nationa l and sub nationa l level. Diversified production of drought- resistant crops, including vegetables, and raising of animals tolerant of heat stress at the household and community levels is promoted and supported. Proportion of households with diversified drought resistant crops and heat tolerant animals. No dat a 25% 45% Survey and Market reports Sectoral line ministries of National and sub- national level Communities and service providers are sensitised on prevention, mitigation and response to risks of malnutrition during shocks. Number of sensitization meetings held on prevention, mitigation and response during shocks 0 40 96 Minutes and list of Participants Sectoral line ministries of National and sub- national level No. of districts with integrated Nutrition and disaster management program 0 20 30 Program quarterly reports Sectoral line ministries of National and sub- national level Increased access to, and utilisation of, nutrition information for emergency response mechanisms. proportion of population accessing Nutrition information through established systems 0% 30% 50% Program reports Sectoral line ministries of National and sub- national level 98 ANNEX 3: STAKEHOLDER CONSULTATIONS Participants of the CRF Launch and consultation in Nairobi, Kenya, May 2018 Name Organisation Email Address 1 Ahmed Abdullahi GIZ Ahmed.abdullahi@giz.de 2 Ali Mohamud Hersi Ministry of Education Aligurey65@gmail.com 3 Abdirahman Yussuf Muse MOH PL Aymuse54@gmail.com 4 Samson Deste Nutrition Cluster sdesie@unicef.org 5 Adan yussuf Mahdi Save the Children International Adan.mahdi@savethechildren.org 6 Dahir Mohamed Noor Ministry of Humanitarian Dg.ds@mohadm.gov.so 7 Ntambi John UNICEF ntambi@unicef.org 8 Meftuh Omar Save the Children International Meftuh.omer@savethechildren.org 9 Muhyidin Mohamed Ministry of Agriculture Meyaasir3m@gmail.com 10 Abdifatah Ibrahim Omar Academic/Jamhuriya University abdifatah@just.edu.so 11 Ismail A Hassan OPM Ismabdi17@gmail.com 12 Ahmed Siyad HPRD ahmed@hornprd.com 13 Muno Almudhwahi WHO almudhwahim@who.org 14 Saida Hassan Ministry of Education and Higher learning Hassan.saida@gmail.com 15 Zeinab Ahmed Academic & Network Zeinabahmed2569@gmail.com 16 Fathi Sheikh Ibrahim Ministry of Fisheries Fathisheikh92@gmail.com 17 Mohamed A Hassan OPM mohamed@opm.gov.so 18 Janet Shinboje CHAN-F jshinboje@gmail.com 19 Barni Noor Sweden Embassy Barni.nor@gov.se 20 Dr Farah OPM Drfarah2011@gmail.com 21 Mohamed Ali Galol Ministry of Labour cmgalool@gmail.com 22 Abdirahman Abdulkadir Sheikh Ministry of Labour Cshoole2@gmail.com 23 Ahmed Abdi Danad Ministry of Labour qaarigolo@hotmail.com 24 Lilian Odhiambo ENN lillian@cnnonline.net Key informers from various sectors/ministries interviewed cross the country in development of CRF and Strategy May 2018 – August, 2018 NAME INSTITUTION EMAIL 99 1 Sadia Mohamed Nur Ministry Of Women Human Right saadianuor@gmail.com 2 Mohamed Abdi Ali Ministry Of Women Human Right youngxeysey@gmail.com 3 Abdiaziz Nur Aid Coordination Unit abdiaziznur@yah00.com 4 Deko Salat Ali Aid Coordination Unit dekosaltadgmail.com 5 Ali Mohamed Hersi Ministry of water aligurey65@gmail.com 6 Mohamed Moalim Osman Environment sector OPM Office bogol1oo@hotmail.com 7 Dahir Mohamed Nuur Ministry of Humanitarian and Disaster Management dgis@gmail,com 8 Abdifatah Ibrahim Omar Jamhuriya University abdifatah@jest.edu.go 9 Abdirizak Hussein Yusuf Ministry of Commerce abdirizzak111@gmail,com 10 Mohamed Malin Ahmed Ministry of Commerce ugaes2@gmail.com 11 Mahamud Mohamed Director General Ministry of Agriculture dg@moa.gov.go 12 Hamuud Ali Hassan Deputy Ministry Agriculture deputyminster@moa.gou. 13 Hassan Mohamed Osman Director General Ministry of Planning kaahuu44@gmail.com 14 Mohamed Ibrahim Adan Ministry of Livestock issevet@gmail.com 15 Mustaf İbrahim Adan Ministry of Livestock mustafdet@gmail.com 16 Abdullahi Sheikh Rashid Makil Somali National University rectoriadmin.makai66@hotmail.com 17 Ahmed Abdi Aden(Iraad) Ministry of Finance iradabdi@hotmail.com 18 Nur Ali Mohamed Director of Planning of MOH 19 Dr Feysal Head of Nutrition for MOH qaasimi770@gmail.com 20 Mr Abdullahi Noor Osman Director of Hormuud Foundation a.osman@hormuud.com Participant of CRF stakeholders Consultation forum in Kismayu, Jubaland - June 2018 Name Institution Mobile Number 1 Samiir Geedow Ministry of Health 613136018 2 Mohamed Nur Ali Ministry of Health 612083000 3 Abdirahman Mohamed Hassan Ministry of Education 612465335 4 Ahmed Siyad HPRD/MQSUN+ 617808086 mailto:SAADIANUOR@GMAIL.COM mailto:ABDIAZIZNUR@YAH00.COM mailto:ALIGUREY65@GMAIL.COM mailto:BOGOL1OO@HOTMAIL.COM mailto:ABDIFATAH@JEST.EDU.GO mailto:UGAES2@GMAIL.COM mailto:DG@MOA.GOV.GO mailto:KAAHUU44@GMAIL.COM mailto:ISSEVET@GMAIL.COM mailto:MUSTAFDET@GMAIL.COM mailto:rectoriadmin.makai66@hotmail.com mailto:IRADABDI@HOTMAIL.COM mailto:qaasimi770@gmail.com mailto:a.osman@hormuud.com 100 5 Mohamed Abdullahi Abdi Somali Youth Dev’t Organization 617594794 6 Dr Abdullahi Sulub Gas Physician Across Continent 616230009 7 Jeele Yarrow Moalim Women Rural dev’t organization 615924991 8 Abdi Hussen Liiban Ministry of Agriculture 619393859 9 Mohamed Ali Hashi Kassima Organization 617799608 10 Mohamed Nur Hassan Ministry of Information 6155634437 11 Abdi Asad Geedi CARE International 612996018 12 Hassan Mohamed Adan Jubaland Commision for Refugees 615107210 13 Mohamud Sahal Ciye Ministry of Education Jubaland State 615856228 14 Abdirashid Jumay Farah Ministry of Health of Jubaland State 619433007 15 Mohamud Shekh Adan IOM 616544063 16 Yussuf Ismail Osman HIMILO 615181963 17 Hassan Mohamud Haji SOMALI AID 612992782 18 Abdi Dinye Shake Save the Children International 616158211 19 Dr Shawo Abdullahi Mohamed PAC 617004492 20 Hafso Mohamed Abdi PAC 618352138 21 Fadumo Ali Adan SOWDO ORGANIZATION 615916273 22 Ramlo Abdullahi Mohamed Ministry Of Fisheries 618780302 23 Safiyo Hussein Muse Ministry Of Livestock 612594514 24 Shugri Gure Geele Moh Malaria Office 616758419 25 Mohamed Abdi Hassan OPM 616968682 26 Mohamed Abdi Farah SUN-FP OPM 617220044 27 Abshir Khalif Shido Jubaland Regional Administration 615942145 28 Mohamed Farah Sheikh Jubaland District Administration 612839512 29 Mohamed Shiiq Adan. Kismayu University 617975809 30 Saciid Abdi Ministry Of Agriculture 613138927 31 Mohamed Muhidin Ministry Of Agriculture 616885610 32 Adan Nuuriye Sanbuur Solutions For Humanity 617990295 33 Abdi Naasir Haji Hassan HIMILO Organization 617166969 34 Abdulqaadir Mohamed Ali Ministry of Health Jubaland 6178755889 35 Ahmed Casayr Haji Ministry of Health 618459220 101 36 Ahmed Ahmed Mercy Health Initiative 616633050 37 Hamza Cali Cumar Kismayo General Hospital 61311767 38 Ebla Mohammed Physician Across Continent 615160892 39 MOHAMED MUKER GIZ 618636303 102 Participant of CRF stakeholders Consultation forum in Garowe, Puntland - August 2018 Name Organization City/Town Email Address/Telephone 1 Mahdi Ali Omar Ministry of Women of Puntland State Garowe mahdafminister@gamil.c om 2 Dr Mohamed Abdi Farah OPM Mogadishu Drfarah2011@gmail.com 3 Ministry of Agriculture(MOA) Garowe MA.wdolive@gmail.com Sucaado Hassan Ali 4 Abdirahman Hassan Yusuf Minister of commerce Garowe Moc.plvov@gmail.com 5 Rahmo Aar Mohamed UNICEF Garowe Mohamad@unicef.org 6 Ali Abdi Ciise WHO Garowe CDC114@gamil.com 7 Suldano Adan Mohamad Ministry of commerce Garowe Jcenxar2030@gmail.com 8 DG ministry commerce Garowe Mohamadabdirizak94@g mail.com Mohamad Abdihakim 9 Siyaad Sahal Dhajad IFEAD Mogadishu siyad@gamil.com 10 Osman Ali Mohamad MOH Puntland Garowe Osman ali57@gmail.com 11 Mohamad Abdi OPM Mogadishu mohassan@opm.org 12 Fadumo Abdirahman OPM Mogadishu fadumoabrahman@gami l.com 13 Feysal Hassan MOH-Focal Nutrition Federal level Mogadishu Drfaisal@gmail.com 14 Mohamed Warsame MOAI Garowe Mohawarsamesomali@g mil.com 15 Abdirahman Yusuf MOH Garowe OYMUC54@gmail.com 16 Mohamad Abdullahi MOH Garowe Mohamadfoot725@gmail .com 17 Dayib Salad Imran UNICEF Garowe Dsismaa@unicef.com Ahmed Siyat MQSUN/HPRD Mogadishu ahmed@hornprd.org 18 Abdirahman Ismail Suleiman MOH Garowe abdirahamansuleyman@ gmail.com 19 University of Bosaso Garowe Shiiqabdi10@gmail.com Abdullahi Sheikh Abdi 20 Mohamed Abdirahman Ciise MOH Garowe Geedi333@gmail.com 21 Mohamad Muhumed MOH Garowe MMSFCCST@gmail.com 22 Mohamed Abdirahman UNIVERSITY OF ADMAS Garowe Gu1014@gmail.com mailto:Drfarah2011@gmail.com mailto:MA.wdolive@gmail.com mailto:Moc.plvov@gmail.com mailto:Mohamad@unicef.org mailto:CDC114@gamil.com mailto:Jcenxar2030@gmail.com mailto:Mohamadabdirizak94@gmail.com mailto:Mohamadabdirizak94@gmail.com mailto:siyad@gamil.com mailto:mohassan@opm.org mailto:fadumoabrahman@gamil.com mailto:fadumoabrahman@gamil.com mailto:Drfaisal@gmail.com mailto:Mohawarsamesomali@gmil.com mailto:Mohawarsamesomali@gmil.com mailto:OYMUC54@gmail.com mailto:Mohamadfoot725@gmail.com mailto:Mohamadfoot725@gmail.com mailto:Dsismaa@unicef.com mailto:ahmed@hornprd.org mailto:abdirahamansuleyman@gmail.com mailto:abdirahamansuleyman@gmail.com mailto:Shiiqabdi10@gmail.com mailto:Geedi333@gmail.com mailto:MMSFCCST@gmail.com mailto:Gu1014@gmail.com 103 23 Mohamed Ahmed MOH Garowe mohamadsheikh@gmail. com 24 Mohamad Adan MOH Garowe Maidarus111@gmail.com 25 Mohamad Ciise UNICEF Garowe MMuhamad@unicef.org 27 Abdirahmaan Hussein\ Ducaale FSNU/FAO Garowe Abdikaraim.duale@fsnu.o rg 28 Ubax Mohamed Hersi UNICEF Garowe ubaji@unicef.org 29 Maryama Nuuradiin Afrah World vision Garowe Maryama- afrah@worlvision.org 30 Naima Abdirizak Hassan MOH Garowe Nacuumi55@gmail.com 31 Daud Hassan Ali Puntland Sun Champion Office Garowe dahimanley@gmail.com 32 Mako Abdi Mohamad MOH Garowe makoabdi@gmail.com 33 Samiiro Mohamad Osman UNFPA Garowe samiirameud@unfpa.org 34 Amit Singh WFP Garowe Amit.sighp@wfp.org 35 Asmo Abdulqadir Nor Ministry of Education Puntland Garowe Asmaar22gmail.com 36 Mohamad Abdisamed Office Vice President Garowe Sun.putlands@gmail.com 37 Dr Abdidirizak Hadisa MOH/ Puntland Garowe Abdirizak30@yahoo.com 38 Abdinasir Mohamed Elmi MOH/ Puntland Garowe Sanweyyne204@gmail.co m 39 Abdirizak Moalim Hersi MOH Garowe sankass@yahoo.com 40 Abulqadir Ali Nuur EU Garowe Abulkaadir.nuur@gmail.c om 41 Ruqiyo Saciid Shire MOHWDAFA Garowe Ruqiyo69@gmail.com 42 Ministry of Women Puntland state Garowe Ubahabdi77@gmail.com Ubax Abdulqaadir Farah 43 Ahmed Siyad HPRD/MQSUN+ Garowe ahmed@hornprd.org 44 Hamdi Abdinasir Abdullahi Puntland MoH Garowe Abdinasir hamdi.796@gmail.com 45 Ayan Omar Mohamed Puntland MoH Garowe Ayaan122gmail.com 46 Nasteho Abdirizack Puntland MOH Garowe Nasteexo7812@gmail.co m 47 Abdiaziz Diriye Hussein Hadma Organization Garowe Hadmapunt@gmail.com mailto:ubaji@unicef.org mailto:Maryama-afrah@worlvision.org mailto:Maryama-afrah@worlvision.org mailto:Nacuumi55@gmail.com mailto:dahimanley@gmail.com mailto:makoabdi@gmail.com mailto:Amit.sighp@wfp.org mailto:sankass@yahoo.com mailto:Ruqiyo69@gmail.com mailto:ahmed@hornprd.org mailto:hamdi.796@gmail.com 104 48 Zakariye Ahmed Mohamed Puntland MOH Garowe Kooshin999@gmail.com 49 Peris Maudana WFP Nairobi Peris.mukuanda@gmail.c om 50 Farah Hassan Ali Puntland MOH Garowe Faraxan9@gmail.com 51 Fadumo Abdullahi Fanax Puntland MOH Garowe Fatma xasan@gmail.com 52 Abdirahman somar Puntland MOH Garowe c/Rahman@gmail.com 53 Maryan Bashir Mohamed Puntland MOH Garowe Samiyo22@gmail.com 54 Abubakar sidow WFP Garowe abubakarsidow@wfp.org mailto:Faraxan9@gmail.com mailto:xasan@gmail.com mailto:c/Rahman@gmail.com mailto:Samiyo22@gmail.com 105 Participant of CRF stakeholders Consultation forum in Baidoa, Bay region- July 2018 Name Organization Location Telephone 1 Ayan Mohamed Mohumed MOH/South West State Baidoa 616215310 2 Abdulle Adan Ali Community Baidoa 615725876 3 Isse Mohammed Issak Save the Children International Baidoa 615948535 4 Adan Ali Mukhtar Student Bay University Baidoa 615610009 5 Abdulqadir Ahmed Gedi Chamber of Commerce Baidoa 615826622 6 Mohamed Hassan Ibrahim Student Bay University Baidoa 615557515 7 Abdirahman Sheikh Muse Chamber of Commerce Baidoa 615808409 8 Abdi Mahad Abdullahi Student Bay University Baidoa 615813668 9 Abdullahi Ali Mohamed Ministry of Labour Baidoa 615804756 10 Abdirahman Sheikh Mohamed Ministry of Planning Baidoa 615813668 11 Yusuf Barre Mahad MOH/South West State Baidoa 615804746 12 Abdisalam Abdullahi Baasal Chamber of Commerce Baidoa 618590001 13 Mohamed Aliyow Barow Minister of Fisheries South West State Baidoa 617657599 14 Salman Abdi Muuse MOH/South West State Baidoa 615243310 15 Ahmed Moalim Abdulqadir Ministry Of Agriculture Baidoa 619620142 16 Abdulqadir Shekh Ali Buulka Civil Society Baidoa 615490080 17 Mohamad Abdi Hasanow Ministry Of Fisheries Baidoa 615819121 18 Diini Abdullahi Mohamed Ministry of Women South West State Baidoa 615590125 19 Adan Abdirahman Ahmed MOH/South West State Baidoa 615943182 20 Ahmed Siyad HPRD/MQSUN+ Baidoa 617808086 21 Abdulqadir Ali Ahmed MOH/South West State Baidoa 619881825 22 Fadumo Abdulkadir Mohamed MOH/South West State Baidoa 615562992 23 Abdirashid Osman Adan MOH/South West State Baidoa 615629575 24 Bintow Abdi Hassan Student Baidoa 615554559 25 Abdi Ali Debey Ministry of Livestock Baidoa 618398251 26 Drs Fartuun Mohamed OPM Baidoa 616496440 27 Dr Faaiso Mohamed Community Baidoa 612348080 106 28 Farax Abdullahi Muus Ministry of Commerce Baidoa 615951137 29 Daud Mustafa Hassan Ministry of Commerce Baidoa 61636193 30 Adan Cumar Hassan Ministry of Agriculture Baidoa 615573917 31 Shugri Bashiir Haaji Member of Parliament Baidoa