Vanuatu National Nutrition Policy & Strategic Plan 2016-2020

Vanuatu Nutrition Policy & Strategic Plan 2016-2020 Ministry of Health/Ministere de la Sante/Ministry Blong Helt Vanuatu National Nutrition Policy & Strategic Plan 2016 -2020 2 Foreword I am very pleased to present the Vanuatu National Nutrition Policy and Strategic Plan 2016-2020 to guide our on-going efforts to protect and promote the health of our people through improved nutrition. In presenting this updated policy, it’s important to acknowledge past nutrition developments and achievements, if somewhat limited. Over the last decade, we have managed to undertake and complete three national surveys to assess the nutrition and health status of our people. This information has enabled us to review and update our national policy and strategic plan for nutrition. We know from the data collected that Non-communicable Disease (NCD) is continuing to increase due to overconsumption of unhealthy foods and living unhealthy lifestyles. The same trend is also observed in other nutrition disorders such as malnutrition and micronutrient deficiencies due to not eating enough nutritious foods. The evidence shows that the situation does not seem to be improving despite our best efforts. The reality is, food plays an important role in our culture. The food we eat affects our health for good or bad. There are many factors that influence the kinds of foods we choose to eat or not to eat, with many being beyond our control. Therefore, it is important to work together to ensure safe and nutritious foods are available, accessible, affordable and acceptable to everyone. This policy and strategic plan represents a comprehensive, multi-sectorial approach to guide how we work together. It presents a range of complementary strategies and actions that we can implement together to improve our national nutrition status. It is crucial that we prioritise and make the investment now in implementing this policy that we may realise a positive return in a healthy, educated and wealthy Vanuatu. On behalf of the Government of Vanuatu, I take this opportunity to thank all stakeholders for your continued support and commitment to strengthening and maintaining the partnerships as we work towards achieving our vision of a healthy educated and wealthy Vanuatu. George Taleo Director General of Health Vanuatu Ministry of Health 3 Acknowledgements The Government of Vanuatu is grateful for the efforts of our committed staff and development partners who supported the preparation of this National Nutrition Policy & Strategic Plan 2016-2020, through the provision of funding, guidance and technical assistance. This document has been developed over a period of several years by committed Ministry of Health staff and partners. It combines the expert advice provided from consultation on the review of the 2006-2010 Nutrition Policy in 2013, and then further several formal and informal consultations in 2015-2016 to create this current document. Special acknowledgements and thanks to the team who lead to the development of the National Nutrition Policy & Strategic Plan 2016-2020: x Karen Fukofuka, WHO Nutrition Consultant x Louisa Tokon, WHO/MOH Nutritionist SSA x Rosie Mohr, Nutritionist (Australian Volunteers for International Development) x Jennifer Timothy, VCH Dietitian and former National Nutrition Coordinator x Tarli O’Connell, World Vision Nutritionist x UNICEF Nutrition Specialists x NCD team x All stakeholders who participated in consultations The Government of Vanuatu also acknowledges the commitment and dedication of those who will be responsible for implementing this policy and strategic plan over the next five years. 4 Table of Contents Foreword .......................................................................................................................................... 2 Acknowledgements........................................................................................................................... 3 Abbreviations .................................................................................................................................... 5 Executive Summary ........................................................................................................................... 6 1.0 Introduction and Background ...................................................................................................... 7 2.0 Policy Context and Directions ...................................................................................................... 8 Goal .............................................................................................................................................. 8 Vision ............................................................................................................................................ 8 Mission ......................................................................................................................................... 8 Purpose ......................................................................................................................................... 8 Policy Objectives ........................................................................................................................... 8 Guiding Principles ......................................................................................................................... 9 International and Regional Guidance ............................................................................................ 9 Links to National Development Process....................................................................................... 10 3.0 Nutrition Situation and Analysis ................................................................................................ 10 Nutrition Governance and Coordination ..................................................................................... 10 Nutrition Capacity and Service Delivery ....................................................................................... 11 Overweight, Obesity and Non-Communicable Disease ................................................................ 11 Under nutrition ........................................................................................................................... 12 Micronutrient Deficiencies .......................................................................................................... 13 Food Security .............................................................................................................................. 13 Nutrition Surveillance and Monitoring ........................................................................................ 14 4.0 Strategic Plan ............................................................................................................................ 15 5.0 Monitoring and Evaluation ........................................................................................................ 21 Appendix:........................................................................................................................................ 28 Appendix 1: ................................................................................................................................. 28 Bibliography .................................................................................................................................... 29 5 Abbreviations AVID DBM DHS HPU IEC Australian Volunteers for International Development Double Burden of Malnutrition Demographic Health Survey Health Promotion Unit – Ministry of Health Information, Education, and Communication MALFFB Ministry of Agriculture, Livestock, Forests, Fisheries and Biosecurity MOE Ministry of Education MOH Ministry of Health NCD Non-communicable Disease NCDU NFNC Non-communicable Diseases Unit – Ministry of Health National Food and Nutrition Committee NSO National Statistics Office NU Nutrition Unit – Ministry of Health NWG PAA Nutrition Working Group Priorities for Action Agenda PEO Provincial Education Office PHO Provincial Health Office RMNCAH SAM SDG Reproductive, Maternal, Neonatal, Child and Adolescent Health Severe Acute Malnutrition Sustainable Development Goals SLO UNICEF State Law Office United Nations Children’s Fund VNNC VCNE WHO Vanuatu National Nutrition Committee Vanuatu College of Nursing Education World Health Organisation 6 Executive Summary This National Nutrition Policy and Strategic Plan 2016-2020 aims to improve the health status of the population through improved nutrition. It defines the policy direction to guide and coordinate our efforts towards ensuring optimal nutrition status for the nation of Vanuatu. Vanuatu is facing a double burden of malnutrition, which means there is currently the presence of under nutrition and overweight and obesity. Furthermore there is evidence of increasing prevalence of non- communicable diseases (NCD). The following policies were developed based on the review of the evidence available on the national nutritional status of the people of Vanuatu. 1. Strengthen nutrition governance and coordination across multiple sectors through partnerships and collaborations to effectively deliver nutrition interventions. 2. Improve delivery and coverage of quality nutrition services. 3. Strengthen interventions targeting the prevention and control of overweight and obesity to reduce the risk of non-communicable diseases. 4. Strengthen interventions to prevent, control and treat under-nutrition, including stunting, wasting and underweight. 5. Prevent and control iron deficiency anaemia, iodine deficiencies and other micronutrient deficiencies among vulnerable populations. 6. Promote and sustain national and household food security. 7. Improve, promote and sustain a nutrition surveillance and monitoring system. Specific strategies and actions are identified as feasible and tailored to the Vanuatu situation, based on work previously undertaken by the Ministry of Health and recommendations from key stakeholders during various consultations. Periodic monitoring and evaluation are essential components to ensure effective and efficient implementation of all development policies and programmes as well as to provide accountability for progress. It is envisaged that the Monitoring & Evaluation framework for this policy will include appropriate indicators and targets that are aligned with the Government’s monitoring processes. Progress reports highlighting success stories and challenges will be shared and communicated through the proposed appropriate mechanisms. Protecting and promoting the health of all people in Vanuatu through improved nutrition requires holistic, multi sectoral approaches and interventions that are evidence based. There are many factors that affect what people eat and thereby affecting their nutrition status. As such, coordination is an essential key to effectively implement this policy. The proposed coordination mechanism is the Vanuatu National Nutrition Committee, along with the Codex and Food Security Council. This document presents the updated national nutrition policy as the previous policy had lapsed in 2010. The strategic plan of action is also included to strengthen the implementation of the policy. 7 1.0 Introduction and Background Nutrition is an integral part of basic human needs and fundamental to health and to the control and prevention of diseases and disability. Just as good nutrition is protective against nutrition related disorders, poor nutrition increases the risk of morbidity and mortality throughout the life course, as well as impeding economic, social, educational and occupational potential. Research shows that good nutrition impacts national development positively and investments in nutrition interventions are increasingly seen as investments in social and human capital that yield returns today and in the future. Nutrition policy has been on the governments agenda since the early 1980’s. Initial nutrition surveys identified the issue of malnutrition among children and the rising rates of NCD’s in the adult population and made recommendations to develop national food and nutrition policy to promote production and consumption of local foods. The first policy was developed by the multi-sectoral Vanuatu National Food and Nutrition Committee (NFNC) in 1986. After approval of the policy, the NFNC became inactive. In 2000, a National Nutrition Taskforce with multi sectoral membership was established to review the policy which was revised and updated in 2006, covering the period from 2006 to 2010. The Taskforce has since been inactive due to lack of coordination and multi-sectoral leadership, limited understanding of nutrition issues among policy makers, and inadequate resource allocation. Additionally, nutrition documentation and records have been lost, making monitoring of progress and evaluation of actions difficult to undertake. Despite these challenges, there have been several notable events in the area of nutrition that has contributed to the food and nutrition policy development in Vanuatu. In 2009, the first National Food Summit was convened to look at ways of ensuring a safe and nutritious food supply1. Then in 2010, the Pacific Food Summit was hosted by the Government of Vanuatu and the Framework for Action on Food Security in the Pacific was released2. In addition to these events numerous surveys have been conducted which have measured nutrition issues in the population and given clear guidance on where interventions are needed in order to see improvement in nutrition status of the population. Unfortunately the surveys conducted over the past several decades show minimal improvements in nutrition status. With Vanuatu’s traditional dietary patterns shifting to contain more unhealthy imported and processed foods, dietary risks have become a key contributor in the rising rates of overweight and obesity and the NCD epidemic. In addition, the consequences of under nutrition such as childhood malnutrition and micronutrient deficiencies continue to be a persistent problem. This has been identified as the ‘double burden of malnutrition’, that is under nutrition and overweight and obesity. In order to tackle these issues a multisectoral approach is needed, with comprehensive nutrition specific and nutrition sensitive interventions. 1 National Food Summit Report. Ministry of Health, Government of Vanuatu, 2009. 2 Pacific Food Summit Report and Framework of Action. www.foodsecurepacific.org 8 2.0 Policy Context and Directions Goal To ensure the national well-being of the total population and increase the access and consumption of healthier locally available foods and balanced diets Vision An educated, healthy and wealthy nation through improved nutrition and health outcomes for all Ni- Vanuatu. Mission To protect and promote the health and nutrition status of all people in Vanuatu through multi-sectoral, coordinated approaches that are evidence based and sustainable. Purpose This document presents a policy direction to guide a comprehensive multi sectoral nutrition response from government, civil society and development partners to address the impact of poor nutrition. The policy demonstrates the Government’s political commitment to improving and protecting the health of its people. This policy recognises the complexity and the interrelatedness of the various factors that affect the nutrition status of populations. It is a tool by which Ministry of Health can better lead, coordinate, organise and guide the interventions of its various departments and stakeholders in order to achieve nutrition targets efficiently and effectively. It is also an advocacy tool to communicate and improve national leaders and policy makers’ understanding of food and nutrition issues in order to enhance decision making processes. This includes mobilising and securing funding support and resources from development partners whose agendas include improving national development through improved nutrition wellbeing of the people of Vanuatu. Policy Objectives 1. Strengthen nutrition governance and coordination across multiple sectors through partnerships and collaborations to effectively deliver nutrition interventions. 2. Improve delivery and coverage of quality nutrition services. 3. Strengthen interventions targeting the prevention and control of overweight and obesity to reduce the risk of non-communicable diseases. 4. Strengthen interventions to prevent, control and treat under-nutrition, including stunting, wasting and underweight. 5. Prevent and control iron deficiency anaemia, iodine deficiencies and other micronutrient deficiencies among vulnerable populations. 6. Promote and sustain national and household food security. 7. Improve, promote and sustain a nutrition surveillance and monitoring system. 9 Guiding Principles The following guiding principles are identified as essential for effective implementation of this policy at all levels. x Commitment to multi-sectoral approaches recognizing the complexity and interrelatedness of the various factors that affects the nutrition status of populations. x Adopt effective coordination mechanisms to ensure recommended actions are implemented according to plans. x Active community participation and ownership to ensure sustainable solutions to nutrition issues. x Adopt a holistic health systems approach built on values of primary health care principles which promotes access and equity of services. x A lifecycle approach must be taken to addressing nutrition, particularly the importance of nutrition in the ‘first 1000 days’ from conception to two years of age to address and prevent the double burden of malnutrition. x Appropriate local foods and practices are promoted. x Gender equality and equity. x Community focused approach to prevention of the double burden of malnutrition. x Accountability and transparency in implementation of the nutrition policy. x Climate change and impact on nutrition for emergency preparedness and response. International and Regional Guidance This policy adopts international and regional guidance to address nutrition issues at a country level from the following documents: x Sustainable Development Goals 2016-2030, in particular SDG two and three. UN, 2016. x The Comprehensive Implementation Plan on maternal, infant and young child nutrition, outlining the global nutrition targets to be achieved by 2025. WHO, 2014. x Action Plan to Reduce the Double Burden of Malnutrition in the West Pacific Region 2015-2020. WHO, 2015. x Approach to nutrition programming in the East Asia and Pacific Region 2014-2025. Vol 1-3. UNICEF. x Global Strategy for Infant and Young Child Feeding. WHO/UNICEF, 2003. x The International Code of Marketing of Breast-milk Substitutes. WHO, 1981. x Global Action Plan for the Prevention and Control of NCDs 2013-2020, outlining the 9 Global Targets for NCD’s. WHO, 2013. x Western Pacific Regional Action Plan for the Prevention and Control of Noncommunicable Diseases 2014-2020. WHO. x Healthy Islands Framework 10 Links to National Development Process The policy objectives are aligned with the Government Priorities for Action Agenda (PAA) 2006-2015, and the Health Sector Strategy 2010-2016. In 2016 the National Sustainable Development Plan 2016-2030 will be released, replacing the PAA; and a new Health Sector Strategy will be developed. The National Nutrition Policy will then require review to align with these documents. The nutritional wellbeing of a population is an indicator of national development as well as it being an essential input for national development. This is clearly acknowledged in the Government’s Priorities for Action Agenda (PAA)3. A healthy, well-nourished and educated population is the best foundation for promoting economic growth and national development. The Ministry of Health in its Health Sector Strategy 2010-20164 identified improving health status of the population as a key sector objective, more specifically through the promotion of healthy diets and lifestyles. This is consistent with the National Roadmap for NCDs 2015-20185 produced by the Ministry of Health to reduce the disease burden due to NCDs. This policy is also aligned with the NCD Policy and Strategic Plan 2016-2020, providing direction on tackling NCD’s. This document is also very much linked to other important national documents which include the following: - Public Health Act - Vanuatu National Breastfeeding Policy - NCD Policy and Strategic Plan 2016-2020 - Vanuatu NCD Roadmap 2015-2018 - National Policy & Strategy for Healthy Islands 2011-2015 - Vanuatu Reproductive Health Policy 2015 and Implementation Strategy 2016-2018 - Food (Control) Act and Food (Control) Regulations - Sweet Drinks Policy, Ministry of Education, 2014. 3.0 Nutrition Situation and Analysis The major nutrition issues Vanuatu is facing are outlined below. Nutrition Governance and Coordination Over the past several decades there has been a lack of coordination and commitment to tackling complex issues of nutrition in Vanuatu. Individual government ministries and development partners implement nutrition specific and nutrition sensitive interventions, however with limited inter-sectoral collaboration. Political commitment at both the national and provincial level is required to coordinate and deliver nutrition interventions. The provision of nutrition specific services is currently under the jurisdiction of the MOH, coordinated through the Nutrition Working Group (NWG). This group however does not hold wide representation of government ministries involved in nutrition sensitive activities. Key sectors including health, education, 3 Priorities and Action Agenda 2006-2016. Department of Economic and Sector Planning, Ministry of Finance and Economic Management, Government of the Republic of Vanuatu. 2006 4 Health Sector Strategy 2010-2016, Ministry of Health, Government of the Republic of Vanuatu. 2010 5 National Policy and Strategy for Non-communicable diseases (NCDs) 2010 -2015. Ministry of Health, Government of the Republic of Vanuatu. 11 agriculture, water and sanitation, environment, finance, trade, legislative and media, as well as civil society and communities must be engaged in the multisectoral nutrition response. Nutrition Capacity and Service Delivery To realise the impact of this policy, nutrition priorities need to be reflected in organisational structures and strategic priorities. The organisational structure and staffing capacity of the MOH currently does not reflect nutrition as a priority. Designated nutrition positions are not filled or adequately resourced, with no designated nutrition officers in Provincial Health Offices. Nutrition sensitive programming is largely donor driven, an unsustainable foundation for realising change. Currently nutrition is taught as part of the school curriculum, as well as nursing college curriculum, however this requires revision to align with current nutrition priorities. Institutional capacity must be further strengthened in order to increase the nutrition capacity of other sectors. Emergency nutrition is also an area of interest that needs further support from the government and supporting partner agencies. As Vanuatu is very prone to experiencing natural disasters such a cyclones, earthquakes, and El-Nino, this directly affects the nutritional status of the population. More focus needs to be put on building the capacity of health staff and strengthening the network of managing nutritional issues during these times of natural disasters. Overweight, Obesity and Non-Communicable Disease Over the past several decades local food systems have been shifting from traditional diets to those largely consisting of nutrient poor, processed foods. These foods tend to be high in salt, sugar, trans-fats, and low in fibre and essential micronutrients. The energy imbalance that occurs from consuming high energy nutrient- poor foods combined with sedentary lifestyles has resulted in the rise of diet related NCD’s including overweight & obesity, diabetes, hypertension, and cardiovascular disease. The prevalence of overweight and obesity among the adult population has been increasing gradually over the past several decades. Among adults approximately 32% are overweight and 19% are obese (NCD STEPS, 2011), with women more likely to be obese compared to men. Prevalence of obesity is also higher in urban areas than rural areas (Vanuatu DHS, 2013). These issues can also be seen rising within the young population with 4.6 % of children less than 5 years being classified as overweight and obese (Vanuatu DHS, 2013). Overweight and obesity is a key risk factor for the development of NCD’s. Diabetes is also increasing quite markedly, particularly among adult men. Rates have increased from 2.8 % of adults in 1998 having diabetes, to 9.3% in 2011. Dietary risk factors contribute the most to development of diabetes and appropriate diet is essential for the management and prevention of complications. Elevated blood cholesterol level and hypertension are both strongly associated with increasing risk of developing cardiovascular diseases, one of the leading causes of premature death in Vanuatu. Reports indicate the prevalence of hypertension among adults is increasing. 28.6% of adults have hypertension, while 36.5% have elevated blood cholesterol (STEPS, 2013). Males are slightly more likely to have hypertension and high cholesterol compared to females. Interventions to tackle nutrition related NCD’s have largely focused on prevention through promotion of healthy diets. Avenues for this have included the media, community health education and programs, and through IEC materials. More action must be taken to integrate nutrition promotion and education into 12 health services and education systems, and to develop targeted nutrition interventions that lead to behaviour change and improved health outcomes. Under nutrition Malnutrition is most common among children due to inadequate maternal nutrition, low birth weight, inadequate breastfeeding, inappropriate introduction of complementary foods, not eating enough nutritious foods, frequent illnesses, parasitic infections and poor sanitation. Improvements in nutrition status of children can reduce the severity of common childhood illnesses, reduce risk of death, reduce risk of NCD’s later in life, and improve cognitive and physical development. The key window of opportunity to address and prevent malnutrition is the ‘first 1000 days’ or from conception through to 2 years of age. Malnutrition among children less than five years of age is a significant public health issue. 28% of children under 5 are stunted, 4% are wasted, and 11% are classified as being underweight (Vanuatu DHS, 2013). The prevalence of stunting increases with age with over one-quarter of children aged 9 months (27%) being stunted and peaking at 24 to 35 months with nearly 40% of children being stunted. Additionally, the prevalence of stunted and wasted children is higher in rural areas than in urban areas; while overweight children are more likely in urban areas than in rural areas (Vanuatu DHS, 2013). Comparison of underweight, wasting and stunting data from 1996 to 2013 indicates little or no improvement in the rates of wasting, and an increase in the prevalence of reported stunting among children. Nearly 11% of children are born with low birth weight (less than 2.5 kg); with mothers with lower education; younger age women (less than 20 years); women from lower socio-economic women and women who smoke more likely to having low birth weight infants (Vanuatu DHS, 2013). Breast milk is the best and complete food available for babies during the first six months of life providing all the nutrients a baby needs for good health. Breastfeeding also reduces risk of developing NCD’s in later life, as well the immediate benefit of lowering risk of diarrhoeal disease, infections and childhood mortality. Infant and young child feeding practices in Vanuatu are currently 73% of infants being exclusively breastfed to 6 months (Vanuatu DHS, 2013). Prevalence of exclusive breastfeeding decreases sharply with age, with less than half of children (48%) aged 20-23 months still being breastfed. Only 29% of children under 5 were fed according to recommended infant and young child feeding practices, with one in four children being fed complementary foods earlier than 6 months (Vanuatu DHS, 2013). Another factor that influences nutrition status, particularly that of infants, is adequate water sanitation and hygiene practices. Only half of the population in Vanuatu have access to improved sanitation. Water from improved sources can be contaminated at collection, during transportation or storage. Only 23% of the population use appropriate water treatment methods. While 63% of households practice safe disposal of child faeces, the households are less likely to safely dispose child faeces of children 0-11 m (36% to 52%). Currently appropriate treatment services for acute malnutrition are being established as an emergency response and preparedness activity, however these require further strengthening and expansion to ensure equitable and sustainable access. Malnutrition is a serious problem as children become severely wasted and have higher chances of mortality, especially in the presence of many other complications that may arise. There is a lack of understanding of the issue of malnutrition in Vanuatu (Wentworth C. 2015), along with a lack of awareness of the extent of the problem due to the absence of effective data collection systems for nutrition indicators. Another challenge is the identification of acute malnutrition at the community level and appropriate referral and provision of treatment. 13 Taking into consideration the high rates of stunting and geographical challenges of accessing treatment for acute malnutrition, prevention initiatives at the community level must be prioritised. Nutrition sensitive interventions also must play a part to improve sanitation, reduce teenage pregnancies, reduce worm infestations and ensure access to nutritious foods. Micronutrient Deficiencies Iron deficiency anaemia among children and pregnant women is a serious public health problem. In children it impairs mental capacity, behaviour and motor development. Low birth weight babies are born with reduced iron stores and have additional requirements for catch up growth (Allen, L., 2000) Iron deficiency also predisposes people to infections through reduced immune functions. Iron deficiency anaemia is a significant public health problem in Vanuatu, most common in young children and women of reproductive age, especially pregnant and breastfeeding mothers. 28% of children aged 6-59 months are anaemic (DHS, 2013), impairing their cognitive, physical and social development, while 22% of women of reproductive age are anaemic, increasing risk of low birth weight babies and capacity to care for their family. Causal factors of iron deficiency anaemia among women include blood loss through menstruation, poor diet, hookworm infestation and haemorrhage during child birth. Iodine deficiency is a public health problem, linked to impaired cognitive development affecting learning capacity of children, goitre, and increased risk of stillbirth and miscarriages in pregnant women. Approximately 60% of non-pregnant women of reproductive age have lower urinary iodine excretion than recommended, indicating iodine deficiency disorder (Li et al, 2008). Of households that use salt, 51% have iodised salt, with urban households were more likely to have iodised salt than rural households (DHS 2013). Several actions have been taken to reduce micronutrient deficiencies, however with little improvements in their prevalence. Pregnant women have access to iron supplementation during pregnancy, however this requires expansion to cover lactating women. Deworming programs are in place and integrated into EPI campaigns. Legislation exists regarding food fortification of flour with iron and iodisation of salt, however due to limited capacity it is not adequately monitored or enforced. Food Security Achieving food security is one of the many necessary prerequisites to improving nutrition outcomes. Food security relies on a population having sufficient quantities of food available on a consistent basis; having sufficient resources to access appropriate foods for a nutritious diet; and using food appropriately based on knowledge of basic nutrition and case, as well as water and sanitation. Its primary focus is ensuring the security of the whole food supply system, which targets wider socioeconomic factors that influence the kinds of food that are available and accessible to people. Consumption of fruit and vegetables is a key indicator of diet quality. Fruit and vegetables are not consumed on a daily basis by the majority of Ni-Vanuatu adults, with approximately 62% of not consuming the recommended 5 serves of fruit & vegetables a day (STEPS, 2011). Available food import data from the National Statistics Office (NSO) indicate changes in dietary consumption patterns, reflecting an increasing shift towards consumption of ‘introduced’ or imported foods which tended to be highly processed and contain high amounts of added sugar, salt and fat. A significant barrier to accessing health food is its cost. Nutrition analysis of the 2010 HIES found that for a household to meet their minimum food and nutrition needs it would cost 261VT, which is higher than the 14 Vanuatu food poverty line of 168vt (Martin, Yi & Fiti, 2015). Another study found that it is largely unaffordable for people to achieve recommended intake of non-starchy fruit and vegetables (Jones & Charlton, 2015). Many of the factors that influence food availability and accessibility are outside the jurisdiction of the health sector, thus requires strong actions from multiple sectors. Nutrition Surveillance and Monitoring The monitoring of nutrition status in Vanuatu in the past has been through national level surveys and ad hoc project evaluations with minimal routine data collection on nutrition indicators within the regular health information systems. Currently underweight is collected through the HIS for children under 5 years old as part of the Well baby clinics. However childhood wasting and stunting data is not collected on a routine basis. In the last year, data for screening and treatment of severe acute malnourished has been collected however this is not a formalised or sustainable data collection system. In order to inform interventions and respond to emergency nutrition situations there is a need to strengthen the surveillance and monitoring of acute malnutrition, along with improving reporting on nutrition interventions to improve practice and measure outcomes. It is also essential that monitoring and evaluation activities are documented and shared among all interested stakeholders. This supports the Ministry of Health’s commitment to good management and the effective and efficient use of available resources. Monitoring and surveillance activities need to be undertaken on a regular basis and results shared and communicated among all stakeholders to guide and improve decision making processes. 15 4.0 Strategic Plan To guide the implementation of the National Nutrition Policy, this Strategic Plan has been developed, stipulating achievable strategies that the Ministry of Health and collaborating partners can take to achieve improvements to the nutrition status of Ni-Vanuatu. Each Policy Objective is broken down into strategies to be achieved within the next five years. Policy Objective 1: Strengthen nutrition governance and coordination across multiple sectors through partnerships and collaborations to effectively deliver nutrition interventions Strategy 1.1 Build a Strong Coordination Structure for Effective Multi-sectoral collaborations and partnerships. Intermediate Outcomes: 1.1.1 The current Nutrition Working Group (NWG) is transitioned into the Vanuatu National Nutrition Committee (VNNC) with wider membership, reporting to the MOH Executive Committee, and with links to the Codex and Food Security Coordinating Council for effective coordination of activities. 1.1.2 Codex and Food Security Coordinating Council oversees completion of the multi- sectorial Vanuatu Plan of Action for Nutrition and Food Security. 1.1.3 Coordination of provincial nutrition activities integrated into Provincial Health Committees Policy Objective 2: Improve delivery and coverage of quality nutrition services. Strategy 2.1 Strengthen institutional and stakeholder capacity for service delivery Intermediate Outcomes: 2.1.1 Nutrition curriculum for Vanuatu College of Nursing Education, including midwifery training, is revised and nurse educators trained, reflecting required skill competencies for delivery of nutrition services and messaging that is evidence-based. 2.1.2 Nutrition and dietetic staff are recruited to fill vacant nutrition positions in the Public Health Dept. and Hospital Dietetic & Foodservice Dept., supported under the recurrent budget of the MOH. 2.1.3 University Scholarships are provided for Ni-Vanuatu in the area of dietetics and public health nutrition to ensure a skilled nutrition workforce for sustainability of nutrition services. 2.1.4 Work with community groups and partners to integrate nutrition promotion and education into community development programmes. 16 Strategy 2.2 Health services are adequately resourced to deliver nutrition services Intermediate Outcomes: 2.2.1 Hospitals, health centres, dispensaries and aid posts equipped with the necessary equipment and supplies to deliver nutrition services. 2.2.2 Review, endorsement and dissemination of the National Guidelines for Healthy Diet and Lifestyles, along with targeted nutrition IEC materials on key topics such as maternal nutrition, infant and young child feeding, salt, anaemia etc. 2.2.3 In-service training and continued professional development is provided to staff on nutrition and key nutrition interventions Strategy 2.3 Improve preparedness and response for nutrition in emergencies Intermediate Outcomes: 2.3.1 Information Management system for collection, analysis and interpretation of data in emergencies is developed. 2.3.2 Endorsed guidance note on management of nutrition supplement donations during emergencies. 2.3.3 Emergency preparedness and contingency/response plans for nutrition are developed. 2.3.4 Incorporate nutrition into both national and provincial emergency preparedness and response plans. Policy Objective 3: Strengthen interventions targeting the prevention and control of overweight and obesity to reduce the risk of non-communicable diseases. Strategy 3.1 Strengthen preventative nutrition interventions to address NCD’s Intermediate Outcomes: 3.1.1 Community survey of salt consumption to inform salt-reduction strategies is conducted in partnership with health research organisation, the George Institute. 3.1.2 Targeted fat, sugar and salt reduction strategies developed, implemented and evaluated. 3.1.3 Healthy catering policy frameworks developed and promoted for adoption by government ministries, departments and private workplaces. 3.1.4 Ministry of Education curriculum development unit supported in ongoing revision of food and nutrition curriculum. 3.1.5 Schools supported to implement the Sweet Drink Policy in schools across Vanuatu as part of Health Promoting Schools Initiative. 17 3.1.6 Schools supported to implement the Healthy School Food Guidelines as part of Health Promoting Schools Initiative. Strategy 3.2 Deliver nutrition interventions that manage and treat diet related NCD’s Intermediate Outcomes: 3.2.1 Clinical nutrition care pathways, guidelines and IEC materials for nutritional management of NCD patients in an inpatient and outpatient setting are developed and implemented. 3.2.2 Develop a cooking program for patient education on preparation of Helti Kakae for different conditions. Strategy 3.3 Support the implementation of legislation targeting risk reduction of NCD’s Intermediate Outcomes: 3.3.1 Legislation on the marketing of food and non-alcoholic beverages to children included in the latest amendments to the food regulations and once endorsed through SLO is enforced by compliance officers. Policy Objective 4: Strengthen interventions to prevent, manage and treat under-nutrition, including stunting, wasting and underweight Strategy 4.1 Strengthen interventions to improve IYCF practices Intermediate Outcomes 4.1.1 Exclusive breastfeeding is promoted for the first 6 months of life and continued breastfeeding to 2 years (World Breastfeeding Week). 4.1.2 Mother Baby Friendly Hospital status is achieved and maintained for all provincial hospitals. 4.1.3 National Breastfeeding policy is revised. 4.1.4 Baby friendly work environments that support breastfeeding mothers are established 4.1.5 National IYCF policy is developed. 4.1.6 Routine health services promote appropriate maternal and infant and young child nutrition for pregnant and lactating women and caregivers of children aged 0-23 months. 18 Strategy 4.2 Establish and strengthen nutrition specific interventions to identify, address and prevent malnutrition among children 0-5 years Intermediate Outcomes 4.2.1 Existing growth monitoring program has essential resources and staff are appropriately trained to effectively monitor growth. 4.2.2 Screening mechanisms for acute malnutrition among children aged 6-59 months are reinforced and established. 4.2.3 Health Facilities providing management of severe acute malnutrition for children aged 0-59 months are reinforced, established and strengthened. 4.2.4 Integrated management of Severe Acute Malnutrition Guidelines Developed Strategy 4.3 Deliver interventions to improve maternal nutrition and birth outcomes Intermediate Outcomes 4.3.1 Nutrition status of pregnant and lactating women is monitored through regular health services. 4.3.2 Nutrition education programs with women’s groups and organisations that support young mothers are developed and implemented. Policy Objective 5: Prevent and control iron deficiency anaemia, iodine deficiencies and other micronutrient deficiencies among vulnerable populations Strategy 5.1 Strengthen interventions to reduce iron-deficiency anaemia at all stages of the lifecycle Intermediate Outcomes 5.1.1 Practice of deworming as part of regular health services is supported and strengthened. 5.1.2 Iron folic acid supplementation provided to pregnant and lactating women in accordance with WHO guidelines. Strategy 5.2 Deliver interventions to treat and prevent Vitamin A deficiency Intermediate Outcomes 5.2.1 Vitamin A and deworming provided during EPI immunisation or other health campaigns. 19 Strategy 5.3 Strengthen legislation to support fortification of foods Intermediate Outcomes 5.3.1 Legislation on fortification of flour with iron and iodised salt are enforced as outlined in the Food Act & Food regulation amendments. 5.3.2 Assess the potential for legislation on fortification on oils and other staple foods. Policy Objective 6: Promote and sustain national and household food security Strategy 6.1 Enhance community awareness of food security issues and strategies to address them Intermediate Outcomes 6.1.1 The School to Home urban food security and nutrition awareness, gardening and cooking program is piloted in Port Vila schools 6.1.2 Media campaigns supported to raise awareness of food security issues Strategy 6.2 Ensure a safe food supply and strengthen food standards for Vanuatu Intermediate Outcomes 6.2.1 Food handlers are trained in food safety, hygiene and nutrition, and criteria for achieving a Food Safety Certificate is enforced as outlined in the Food Regulation Act. 6.2.2 Amendments to the Food Regulations are enforced by compliance officers to ensure a safe food supply and strengthened food standards for Vanuatu Policy Objective 7: Improve, nutrition promote and sustain a comprehensive nutrition surveillance and monitoring system Strategy 7.1 Strengthen national information management and monitoring systems to enable reporting on nutrition indicators and identification of emerging challenges Intermediate Outcomes 7.1.1 Nutrition indicators relating to stunting integrated into the HIS to support monitoring of population nutrition status. 7.1.2 Conduct supervisory visits to provinces to monitor the implementation of national strategy at the provincial and community level. 7.1.3 Develop a centralised database using existing data collection systems to capture data on nutrition indicators. 20 Strategy 7.2 Develop mechanisms to effectively monitor and evaluate policy implementation at all levels. Intermediate Outcomes 7.2.1 Monitoring & Evaluation framework is developed and implemented for this plan to monitor implementation progress, effectiveness and reach of interventions. 7.2.2 M&E meeting with key stakeholders in the VNNC is conducted to review progress of strategic plan implementation. 7.2.3 M&E and Surveillance reports are disseminated widely to all stakeholders to inform them of outcomes. 21 5.0 M onitoring and Evaluation Periodic m onitoring and evaluation are essential com ponents to ensure effective and efficient im plem entation of all developm ent policies and program m es as w ell as to provide accountability for progress. Policy Objective 1: Strengthen nutrition governance and coordination across m ultiple sectors through partnerships and collaborations to effectively deliver nutrition interventions Strategies Interm ediate O utcom es Indicators Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Responsibility Lead Support 1.1 Build a strong coordination structure for effective m ulti-sectoral collaborations and partnerships 1.1.1 The current N utrition W orking Group (N W G ) is transitioned into the Vanuatu N ational N utrition Com m ittee (VN N C) w ith w ider m em bership, reporting to the M O H Executive Com m ittee, and w ith links to the Codex and Food Security Coordinating Council for effective coordination of activities. VN N C m eeting m inutes, TO R and annual report X X X X X M O H, N W G N U , CO DEX 1.1.2 Codex and Food Security Coordinating Council oversees com pletion of the m ulti-sectorial Vanuatu Plan of Action for N utrition and Food Security. Vanuatu PO A for N utrition and Food Security developed X X X CO DEX VN N C 1.1.3 Coordination of provincial nutrition activities integrated into Provincial Health Com m ittees Provincial Health Com m ittee m eeting m inutes and TO R. X PHO , NU , VN N C N G O partners; hospitals Policy Objective 2: Im prove delivery and coverage of quality nutrition services Strategies Interm ediate O utcom es Indicators Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Responsibility Lead Support 2.1 Strengthen institutional and stakeholder capacity for service delivery 2.1.1 N utrition curriculum for Vanuatu College of N ursing Education, including m idw ifery training, is revised and nurse educators trained, reflecting required skill com petencies for delivery of nutrition services and m essaging that is evidence-based. Revised nutrition curriculum Training register X X N U , VCN E PHO 2.1.2 N utrition and dietetic staff are recruited to fill vacant nutrition positions in the Public Health Dept. and Hospital Dietetic & Foodservice O ne vacant nutrition position X X X M O H PHO 22 Dept., supported under the recurrent budget of the M O H. in the M O H structure filled annually 2.1.3 U niversity Scholarships are provided for N i-Vanuatu in the area of dietetics and public health nutrition to ensure a skilled nutrition w orkforce for sustainability of nutrition services. 3 scholarships provided to Ni- Vanuatu X X X Funding partners, Scholarships office 2.1.4 W ork w ith com m unity groups and partners to integrate nutrition prom otion and education into com m unity developm ent program m es. 4 program s w ith nutrition integrated X X X X N U , N GO partners, PHO 2.2 H ealth services are adequately resourced to deliver nutrition services 2.2.1 Hospitals, health centres, dispensaries and aid posts equipped w ith the necessary equipm ent and supplies to deliver nutrition services. Lists for annual procurem ent and distribution of supplies X X X X X M O H, CM S, VN N C U N ICEF, N G O partners 2.2.2 Review , endorsem ent and dissem ination of the National Guidelines for Healthy Diet and Lifestyles, along w ith targeted nutrition IEC m aterials on key topics such as IYCF, salt, anaem ia etc. G uidelines endorsed; 2 IEC m aterials developed and dissem inated annually X X X X X N U HPU , PHO 2.2.4 In-service training and continued professional developm ent is provided to staff on nutrition and key nutrition interventions Training registers X X X X X N U , N GO partners PHO 2.3 Im prove preparedness and response for nutrition in em ergencies 2.3.1 Inform ation M anagem ent system for collection, analysis and interpretation of data in em ergencies is developed. IM system developed X N U HIS, W HO , U N ICEF 2.3.2 Endorsed guidance note on m anagem ent of nutrition supplem ent donations during em ergencies. 1 guidance note developed and dissem inated X N W G N DM O 2.3.3 Em ergency preparedness and contingency/response plans for nutrition are developed. Preparedness & response plans developed X N W G PHO , NU , U N ICEF, M O H 2.3.4 Incorporate nutrition into both national and provincial em ergency preparedness and response plans. N utrition m ainstream ed into em ergency preparedness plans X X N W G PHO , NU , U N ICEF, M O H 23 Policy Objective 3: Strengthen interventions targeting the prevention and control of overw eight and obesity to reduce the risk of non-com m unicable diseases. Strategies Interm ediate O utcom es Indicators Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Responsibility Lead Support 3.1 Strengthen preventative nutrition interventions to address N CD’s 3.1.1 Com m unity survey of salt consum ption to inform salt-reduction strategies is conducted in partnership w ith health research organisation, the G eorge Institute. Salt survey com pleted X M O H - N CDU , HPU , N U G eorge Institute, N SO , W HO 3.1.2 Targeted fat, sugar and salt reduction strategies developed, im plem ented and evaluated. A fat, sugar and salt reduction strategy produced X X N U , N CDU , HPU W HO 3.1.3 Healthy catering policy fram ew orks developed and prom oted for adoption by governm ent m inistries, departm ents and private w orkplaces. N um ber of w orkplaces w ith healthy catering policies X N U , Dept. Labour G ov. M inistries, Business Sector, Churches 3.1.4 M inistry of Education curriculum developm ent unit supported in ongoing revision of food and nutrition curriculum . Revised curriculum X M O E, N U 3.1.5 Schools supported to im plem ent the Sw eet Drink Policy in schools across Vanuatu as part of Health Prom oting Schools Initiative. 50% schools im plem enting the SDP X X X X X M O E, PEO , HPS, N U , HPU 3.1.6 Schools supported to im plem ent the Healthy School Food Guidelines as part of Health Prom oting Schools Initiative. 50% schools im plem enting Healthy School Food G uidelines X X X X M O E, PEO , HPS N U , HPU 3.2 Deliver nutrition interventions that m anage and treat diet related N CD’s 3.2.1 Clinical nutrition care pathw ays, guidelines and IEC m aterials for nutritional m anagem ent of N CD patients in an inpatient and outpatient setting are developed and im plem ented. Clinical nutrition pathw ays and guidelines developed X X VCH, AVID 3.2.2 Develop a cooking program for patient education on preparation of Helti Kakae for different conditions. Cooking program established and functioning X X X X VCH, Dietetics Dept., M O H, N U 3.3 Support the im plem entation of legislation targeting risk reduction of N CD’s 3.3.1 Legislation on the m arketing of food and non-alcoholic beverages to children included in the latest am endm ents to the food regulations and once endorsed through SLO is enforced by com pliance officers. Endorsed legislation Com pliance officer reports X X X X X EHU , SLO N U , W HO 24 Policy Objective 4: Strengthen interventions to prevent, m anage and treat under-nutrition, including stunting, w asting and underw eight Strategies Interm ediate O utcom es Indicators Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Responsibility Lead Support 4.1 Strengthen interventions to im prove IYCF practices 4.1.1 Exclusive breastfeeding is prom oted for the first 6 m onths of life and continued breastfeeding to 2 years (W orld Breastfeeding W eek). Annual report of breastfeeding prom otion activity X X X X X HPU , N U , RM N CAH PHO , NG O partners 4.1.2 M other Baby Friendly Hospital status is achieved and m aintained for all provincial hospitals. 2 hospitals accredited as M BFHI each year X X X M O H, Provincial Hospitals W HO , U N ICEF 4.1.3 N ational Breastfeeding policy is revised. Policy revised X M O H - N U , RM N CAH, VCH Com m unity groups, Labour dept. 4.1.4 Baby friendly w ork environm ents that support breastfeeding m others are established O ne baby friendly w ork place established annually X X X X X M O H - N U , RM N CAH Labour dept., w orkplaces 4.1.5 N ational IYCF policy is developed. Policy developed X N U , U N ICEF 4.1.6 Routine health services prom ote appropriate m aternal and infant and young child nutrition for pregnant and lactating w om en and caregivers of children aged 0-23 m onths. 50% of pregnant w om en and caregivers receive IYCF counselling X X X X X N W G N G O partners, U N ICEF, PHO 4.2 Establish and strengthen nutrition specific interventions to identify, address and prevent m alnutrition am ong children 0-5 years 4.2.1 Existing grow th m onitoring program has essential resources and staff are appropriately trained to effectively m onitor grow th. All health facilities have appropriate tools and skills for grow th m onitoring X X X M O H, N W G U N ICEF, W HO 4.2.2 Screening m echanism s for acute m alnutrition am ong children aged 6-59 m onths are reinforced and established. Health facility reports X X X X X M O H PHO , SCA 4.2.3 Health Facilities providing m anagem ent of severe acute m alnutrition for children aged 0-59 m onths are reinforced, established and strengthened 6 hospitals w ith functional capacity to treat and m anage SAM X X U N ICEF, Provincial Hospitals M O H 4.2.4 Integrated m anagem ent of Severe Acute M alnutrition G uidelines Developed N ational Integrated SAM Guidelines Developed X M O H, U N ICEF N G O Partners and Stakeholders 25 4.3 Deliver interventions to im prove m aternal nutrition and birth outcom es 4.3.1 N utrition status of pregnant and lactating w om en is m onitored through regular health services. Reports from health facilities X X X X X M O H – PHO , NU 4.3.2 N utrition education program s w ith w om en’s groups and organisations that support young m others are developed and im plem ented. Evaluation reports of program s delivered X X X N U DO J- W om en, N VW C, N G O ’s, Churches Policy Objective 5: Prevent and control iron deficiency anaem ia, iodine deficiencies and other m icronutrient deficiencies am ong vulnerable populations Strategies Interm ediate O utcom es Indicators Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Responsibility Lead Support 5.1 Strengthen interventions to reduce iron- deficiency anaem ia at all stages of the lifecycle 5.1.1 Practice of dew orm ing as part of regular health services is supported and strengthened. 75% national coverage of dew orm ing X X X X X N TD, EPI, PEO ’s 5.1.2 Iron folic acid supplem entation provided to pregnant and lactating w om en in accordance w ith W HO guidelines. 30% reduction in prevalence of anaem ia X X X X X RM N CAH, N U U N ICEF 5.2 Deliver interventions to treat and prevent Vitam in A deficiency 5.2.1 Vitam in A and dew orm ing provided during EPI im m unisation or other health cam paigns. 90% of children (6- 59 m onths) receive vitam in A and dew orm ing X X X X X EPI, N TD U N ICEF, W HO 5.3 Strengthen legislation to support fortification of foods 5.3.1 Legislation on fortification of flour w ith iron and iodised salt are enforced as outlined in the Food Act & Food regulation am endm ents. Com pliance officer reports on legislation enforcem ent X X X X X EHU , SLO M O H, CO DEX 5.3.2 Assess the potential for legislation on fortification on oils and other staple foods. Feasibility assessm ent undertaken X X X W HO Policy Objective 6: Prom ote and sustain national and household food security Strategies Interm ediate O utcom es Indicators Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Responsibility Lead Support 6.1 Enhance com m unity aw areness of food security issues and 6.1.1 The School to Hom e urban food security and nutrition aw areness, gardening and cooking program is piloted in Port Vila schools Pilot program delivered X FAO N G O partners, M O H, M ALFFB 26 strategies to address them 6.1.2 M edia cam paigns supported to raise aw areness of food security issues O ne m edia cam paign annually – W orld Food Day. X X X X X M ALFFB, FAO , M edia M O H, M O E, VN N C, N G O partners 6.2 Ensure a safe food supply and strengthen food standards for Vanuatu 6.2.1 Food handlers are trained in food safety, hygiene and nutrition, and criteria for achieving a Food Safety Certificate is enforced as outlined in the Food Regulation Act. Training delivered in each province tw ice a year X X X X X EHU , NU PHO , CO DEX 6.2.2 Am endm ents to the Food Regulations are enforced by com pliance officers to ensure a safe food supply and strengthened food standards for Vanuatu Endorsed Food Regulations Legislation enforcem ent reports X X X X X EHU SLO , M O H, M O TCCI, Custom s Policy Objective 7: Im prove, nutrition prom ote and sustain a com prehensive nutrition surveillance and m onitoring system Strategies Interm ediate O utcom es Indicators Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Responsibility Lead Support 7.1 Strengthen national inform ation m anagem ent and m onitoring system s to enable reporting on nutrition indicators and identification of em erging challenges 7.1.1 N utrition indicators integrated into the HIS to support m onitoring of population nutrition status. HIS reporting form s X X N W G , HIS W HO , PHO , M O H 7.1.2 Conduct supervisory visits to provinces to m onitor nutrition activities at the provincial and com m unity level. 3 supervisory visits annually X X X X X N U N G O partners 7.1.3 Develop a centralised database using existing data collection system s to capture data on nutrition indicators. Centralised database developed X N U , VN N C M O H 7.2 Develop m echanism s to effectively m onitor and evaluate policy im plem entation at all levels 7.2.1 M onitoring & Evaluation fram ew ork is developed and im plem ented for this plan to m onitor im plem entation progress, effectiveness and reach of interventions. M & E Fram ew ork developed X VN N C M O H 7.2.2 M & E m eeting w ith key stakeholders in the VN N C is conducted to review progress of strategic plan im plem entation. Annual M & E m eeting conducted X X X X X VN N C 7.2.3 M & E and Surveillance reports are dissem inated w idely to all stakeholders to inform them of outcom es. Report dissem inated X X X X X VN N C 27 Monitoring and evaluation for activity level will be developed on an annual basis in line with business planning processes. Data will be collected regularly in order to measure progress against set targets. Operational research will also be carried out to address specific problems identified during the implementation of nutritional activities. Progress reports highlighting success stories and challenges will be shared and communicated to stakeholders through the Vanuatu National Nutrition Committee. Based on the Global Nutrition Targets outlined within the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition , these strategies will also be measured according to the National Targets as described in the table below. Table 1 Global and National Nutrition Targets Global Nutrition Targets 2025 Vanuatu Baselines and Progress (2013 DHS) Vanuatu Targets for 2025 40% reduction in the number of children under 5 who are stunted 32 % 20 % 50% reduction of anaemia in women of reproductive age 24.5% 12 % 30% reduction in low birth weight 10.1 % 7 % No increase in childhood overweight 4.6 % Maintain zero increase in rate of overweight Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% 72 % at 0 - 5 months Maintain current rate with a minimum of 50% at 6 months Reduce and maintain childhood wasting to less than 5% 4.4 % Maintain at less than 5 % Nutrition surveys and epidemiologic surveillance will be conducted regularly in close collaborations with the National Statistics Office (NSO) and stakeholders, with appropriate indicators, to evaluate the progress and impact of nutrition interventions. Activity costing for the Nutrition Strategic Plan 2016-2020 will be available on an annual basis in accordance with the national health sector business planning cycle. Annual budget projections will allow for greater accuracy in financial allocations as well as flexibility in activity expansion or contraction based on the level of government and donor support for nutrition services in any given year. 28 Appendix: Appendix 1: Acknowledgement for the support and input into this Nutrition Policy and Strategic Plan goes to the following people and their organisations: Mrs. Tina Soaki Lau Ministry of Trade (CODEX) Mr. Glenden Illasa Ministry of Education Mr. Pierre Gambetta Health Promoting Schools Committee Mr. Knox Morris Disability Desk, Ministry of Justice Mr. Rennie Ngwele Seventh Day Adventist Church Mrs. Prescilla Meto Vanuatu Christian Council Mrs. Shirley Laban World Vision Dr Sophaganine Ty Save the Children Mr. Junaid Ullah UNICEF Dr. Uma Palaniappan UNICEF Ms. Emma Dorris Wan Smol Bag Mrs. Annick Stevens National Council of Women Ms. Dorinda Bule VBTC Mr. Jonas Cullwick Daily Post Mrs. Viviane Obed Care International Mrs. Margaret Lui Pharmacy, VCH Mrs. Hannah Kanas NCD Clinic, Vila Central Hospital Mrs. Monique Tahi Eye Care, Vila Central Hospital Mrs. Jenny Bong Dental, Vila Central Hospital Mr. John Tasserei Health Promotion, Ministry of Health Mr. Graham Tabi NCDs, Ministry of Health Ms. Lana Elliott NCDs, Ministry of Health Ms. Louisa Tokon Nutrition, WHO Ms. Rosie Mohr Nutrition, WHO Mrs. Myriam Abel Primary Health Care, WHO Mr. Jerry Iaruel Mental Health, Ministry of Health Dr. Chelsea Wentworth University of Pittsburgh Sincere thanks go to all whose valuable input played a part in the development of this policy and strategic plan. 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