National Food and Nutrition Strategic Plan 2013-2018

REPUBLIC OF RWANDA NATIONAL FOOD AND NUTRITION STRATEGIC PLAN 2013-2018 Rwanda National Food and Nutrition Strategic Plan Ministry of Local Government http://www.minaloc.gov.rw/ Ministry of Health http://www.moh.gov.rw/ Ministry of Agriculture and Animal Resources http://www.minagri.gov.rw/ Kigali: Republic of Rwanda, January 2014 ii Foreword Rwanda’s plans for economic development and poverty reduction include food and nutrition as a foundational pillar for a healthy population. It is against this background that the Ministry of Health developed this National Food and Nutrition Strategic Plan for the years 2103-2018. The strategic plan implements the revised National Food and Nutrition Policy that recommends actions to b taken aimed at sustaining this s position and provides innovative multi-sector and sector specific strategic directions to assure that in Rwanda food and nutrition improvement remains everyone’s commitment. Like the Policy this Strategic Plan recognises and focuses on the national resolve to substantially reduce the prevalence of stunting among children under two years of age, and to improve household food security particularly among the most vulnerable families. While substantial reduction of acute malnutrition has occurred in recent years, there remain challenges with high levels of chronic malnutrition and micronutrient deficiency. When pregnant women do not have appropriate nutritional intake during pregnancy, and children do not receive the foods, feeding and care required for normal growth during their first two years, chronic malnutrition occurs. The National Food and Nutrition Policy (NFNP) updates and revises the National Nutrition Policy of 2007. The linkage of nutrition, household food security and social protection is reinforced through the Policy’s expanded multi-sector ownership and implementation responsibilities. The NFNP explains the rationale and broadened scope of the updated version and provides a conceptual framework useful in addressing current problems. The NFNP is fully in line with the EDPRS II foundational issue of food and nutrition and related objectives. The Policy recommends and outlines both sector specific and multi-sector strategic directions. The strategic directions follow and expand on relevant sector policies and strategies. The NFNP provides the base for the National Food and Nutrition Strategic Plan (NFNSP) 2013 2018. The NFNSP is intended to guide NFNP implementation a five years period that will include special emphasis on the prevention of child stunting. The NFNSP attempts to bring together, for families, many interventions that protect women and children during the 1 st 1000 Days, a “window of opportunity” that begins at pregnancy and continues through the first two years of life when most stunting occurs. The NFNSP takes into account the complex causal relationships that link nutrition, infection, household food security, and social protection. The importance of addressing each of these factors and their linkages explain the need for NFNP and NFNSP to have a multi-sector ownership and joint implementation responsibilities. Remaining fully in line with the objectives of the EDPRS II and selection of food and nutrition as a foundational commitment, the NFNSP 2013-2018 both adopts and strives to strengthen related policies and strategies of the Social Cluster Ministries and also lays out a multi-sector strategic direction that targets households across the country. iii The NFNSP also provides logical frameworks that include planned outputs and key activities for each strategic direction. The adoption and promulgation of the National Food and Nutrition Strategic Plan reaffirms the commitment of the Government of Rwanda to ensuring a balanced dietary intake of nutritious foods and household food security for the nations’ population. iv Table of Contents 1. NFNP Rationale and Scope of the NFNP and NFNSP 2013-2019 ...................................... 8 1.1 Background ....................................................................................................................... 8 1.2 The linkage of the NFNP to other National and International Policies and Policy level documents .................................................................................................................... ...............11 1.2.1 Rwanda VISION 20/20.........................................................................................................12 1.2.2 Economic Development and Poverty Reduction Strategy 2 ............................................. 12 1.2.3 Health Sector Strategic Plan III ............................................................................................12 1.2.4 Linkage with other GOR Sector Policies and Strategies ...............................................12 1.2.5 Global and Regional Conventions ...................................................................................13 2. Situation Analysis ...........................................................................................................14 2.1 Factors leading to revisions in the NFNP and NFNSP 2013-2018 ...................................14 2.1.1 National Nutrition Policy 2007 ...................................................................................14 2.1.2 Political context and key events leading to NFNP update and revision ...............................15 2.2 Malnutrition and related factors in Rwanda: trends, progress and gaps .......................18 2.2.1 Multiple Conditions affecting Optimal Nutrition ...........................................................18 2.2.2 Acute malnutrition ...........................................................................................................19 2.2.3 Chronic malnutrition ...........................................................................................................19 2.2.4 Maternal, Infant, Young Child and Nutrition (MIYCN) ...............................................20 2.2.5 Micronutrient Deficiencies ...............................................................................................21 2.2.6 Food, Nutrition and HIV/AIDS ...................................................................................23 2.2.7 Hygiene, Sanitation and Safe Water ...................................................................................23 2.2.8 Over nutrition and Chronic Disease ...................................................................................24 2.3 Household Food Security ...............................................................................................24 2.4 Social Protection and Malnutrition ...................................................................................26 2.5 Nutrition, Household Food Security and the Family ...........................................................27 2.5.1 Laws addressing basic Issues that affect malnutrition ...............................................27 v 2.5.2 MIGEPROF national level nutrition promotion ...........................................................27 2.5.3 Support for community level nutrition improvement ...........................................................27 2.6 Food and Nutrition in Schools ...................................................................................28 2.6.1 Teaching and learning about Food and Nutrition ...........................................................28 2.6.2 School feeding ...........................................................................................................28 2.7 Food and nutrition in emergencies ...................................................................................29 2.7.1 Food and Nutrition for Refugees ...................................................................................29 2.8 Additional Information sources informing the development of the NFNSP .......................30 2.9 Achievements under the 2007 National Nutrition Policy and challenges remaining in 2013 ...............................................................................................................................................30 2.10 Conceptual Framework for the National Food and Nutrition Policy ...................................36 2.11 Vision, Mission and Objectives of the National Food and Nutrition Strategic Plan 2013 2018 ............................................................................................................................. ..................38 2.11.1 NFNP Vision .......................................................................................................................38 2.11.2 NFNP Mission ...........................................................................................................38 2.12 NFNP Objectives and Outcomes ...................................................................................38 2.12.1 General objective ...........................................................................................................38 2.12.2 Specific of objectives of the NFNSP ...................................................................................38 2.12.3 Strategic objectives and key expected outcomes ...........................................................38 2.13 Strategic Plan priorities for improving nutrition and household food security ...........41 2.13.1 Principles behind the Policy’s Strategic Directions ...........................................................41 2.14 Strategic Directions of the NFNP ...................................................................................43 2.14.1 Strategic Direction 1: Food and nutrition advocacy to sustain commitment and generate resources for implementation ...........................................................................................................43 2.14.2 Strategic Direction 2: Prevention of Chronic Malnutrition ...............................................47 2.14.3 Strategic Direction 3: Improving Household Food Security ...............................................56 2.14.4 Strategic Direction 4: Prevention and management of all forms of malnutrition ...........65 Outputs and Key activities ...........................................................................................................70 vi 2.14.5 Strategic Direction 5: Improving food and nutrition in schools ...................................74 2.14.6 Strategic Direction 6: Assuring food and nutrition in emergencies ...................................79 2.14.7 Strategic Direction 7: Supporting programmes and services ...............................................83 2.15 Implementation plan and management framework ...........................................................91 2.16 Leadership and coordination at national and decentralized Levels ...................................92 2.16.1 Joint NFNSP ownership and implementation responsibility ...............................................92 2.16.2 Coordination and leadership ...............................................................................................92 2.17 NFNSP stakeholder roles and responsibilities .........................................................95 3. Monitoring, Evaluation and Operational Research .........................................................109 3.1 National level NFNSP monitoring .................................................................................109 3.2 District level NFNSP monitoring .................................................................................109 3.3 Community level NFNSP monitoring .....................................................................109 3.4 Operational Research Agenda ............................................................................................110 4. Resource allocation and mMbilisation .....................................................................110 5. Conclusion .....................................................................................................................111 Main Background Documents .............................................................................................114 Persons consulted and/or participating in workshops for the development of the .....................117 vii Acronyms AIDS Acquired Immunodeficiency Syndrome AMIS Agriculture Management Information System ANC Antenatal Care ART Antiretroviral Therapy ARV Antiretroviral ASWG Agriculture Sector Working Group BCC Behaviour Change Communication BFHI Baby Friendly Hospitals Initiatives BMI Body Mass Index BNR National Bank of Rwanda CAADP Comprehensive Africa Agriculture Development Programme CBNP Community-Based Nutrition Program CFE Common Framework of Engagement CFSVA/NS Comprehensive Food Security and Vulnerability Analysis and Nutrition Survey CHAI Clinton Health and AIDS Initiative CHWs Community Health Workers CICA Agricultural Information and Communication Centre CIP Crop Intensification Program CRS Catholic Relief Services CSB Corn Soy Blend (fortified supplementary food) CSBC Communication for Social and Behavioural Change DFID Department for International Development (United Kingdom) D/MD Deputy / Managing Director DDP District Development Plan DF&NSC District Food and Nutrition Steering Committee DG Directorate General / Director General DHS Demography and Health Survey DHIS2 District Health Information System-2 (combines HMIS and SISCOM) DP Development Partners DPEM District Plan to Eliminate Malnutrition EAC East African Community ECD Early Child Development EDPRS Economic Development and Poverty Reduction Strategy EFA Education for All EICV Enquête Intégrale sur les Conditions de Vie des ménages EKN Embassy of the Kingdom of the Netherlands EPEM Emergency Plan to Eliminate Malnutrition ESSP Education Sector Strategic Plan (2010-2015) EU European Union FEWS Famine Early Warning System FAO Food and Agriculture Organisation viii FBOs Faith Based Organisations FCS Food Consumption Score 1st 100 Days CBF&NP 1st 1000 Days Community Based Food and Nutrition Programme FOSA Formations sanitaires (Health Centres) FP Family Planning FSNMS Food Security and Nutrition Monitoring System GAIN Global Alliance for Improving Nutrition GAVI Global Alliance for Vaccines and Immunisation GDP Gross Domestic Product GIRINKA One Cow per Poor Family Programme GoR Government of Rwanda HGSFP Home Grown School Feeding Program HSS Hygiene and Sanitation in Schools HH Household(s) HIV Human Immunodeficiency Virus HMIS Health Management Information System HSG Health Sector Group HSSP III Health Sector Strategic Plan III HSTWG Health Sector Technical Working Group I&M TF Irrigation and Mechanisation Task Force ICCIDD International Council against Iodine deficiency diseases IEC Information Education and Communication IGA Income Generating Activities IMCC Inter-Ministerial Coordination Committee IMCi Integrated Management of Childhood Illness IPC Integrated Food Security Phase Classification IRC International Rescue Committee ISAR Institute of Agronomic Sciences in Rwanda ISLC Integrated Survey on household Living Conditions IUGR Intra-uterine growth retardation IYCF Infant and Young Child Feeding JAPEM Joint Action Plan to Eliminate Malnutrition KAP Knowledge, Attitude and Practice KHI Kigali Health Institute KIE Kigali Institute of Education MCC Milk collection centre MCH Maternal and Child Health MDG Millennium Development Goal MFI Micro-finance Institution MIFOTRA Ministry of Public Service and Labour MIGEPROF Ministry of Gender and Family Promotion MINADEF Ministry of Defence ix MINAFFET Ministry of Foreign Affairs and Cooperation MINAGRI Ministry of Agriculture and Animal Resources MINALOC Ministry of Local Government MINECOFIN Ministry of Finance and Economic Planning MINEDUC Ministry of Education MINISANTE Ministry of Health MINIJUST Ministry of Justice MININFRA Ministry of Infrastructure MINICOM Ministry of Trade and Industry MINIRENA Ministry of Natural Resources (land forests, environment and mining) MIDIMAR Ministry of Disaster Management and Refugees MIYCN Maternal Infant and Young Child Nutrition MYICT Ministry of Youth and ICT MINISPOC Ministry of Sport and Culture MIS Management Information System MND Micronutrient Deficiency MNP Micronutrient Powder “Sprinkles” (for in-home fortification of complementary foods) MTEF Mid Term Expenditure Framework MUAC Middle Upper Arm Circumference NAEB National Agricultural Export Development Board NAP Nutrition Action Plan (MINAGRI) NAS European Community Nutrition Advisory Service NFNP National Food and Nutrition Policy NFNSP National Food and Nutrition Strategic Plan (2013-2018 NCDs Non Communicable Diseases NEPAD New Partnership for Africa’s Development NF&NTWG National Food and Nutrition Technical Working Group NGO Non-Governmental Organisation NISR National Institute of Statistics of Rwanda NmSEM National multisector Strategy for Elimination of Malnutrition (2010-20130) NNP National Nutrition Policy NTDs Neglected Tropical Diseases NTWG Nutrition Technical Working Group NUR National University of Rwanda NWCVC National Women’s Council Village Committee. ONE UN UN system in Rwanda OVCs Orphans Vulnerable Children PHHS Post-Harvest Handling and Storage PLHIV People living with HIV/AIDS PMO Prime Minister Office PMTCT Prevention of Mother to Child Transmission PRSP Poverty Reduction and Strategy Paper x PSTA Strategic Plan for Agricultural Transformation PTAs/PTCs Parents and Teachers Associations/ Parents and Teachers Councils RAB Rwanda Agriculture Board RapidSMS Cell phone based system used by Community Health Workers RDB Rwanda Development Board RDHS Rwanda Demographic and Health Survey REACH Renewed Efforts Against Child Hunger SACCO Savings and Credit Co-operative SCF&NSC Social Cluster Ministries Food and Nutrition Steering Committee SIS National Health Information system SISCOM (French acronym for) Community Health Information System SOSOMA Sorghum, Soybean Maize blend (Supplementary food) STIs Sexually Transmitted Infections SUN Scaling Up Nutrition TB Tuberculosis TTCs Teachers Training Centres U2 Under-two years old children U5 Under-five years old children UN United Nations UNAIDS UN AIDS Organisation UNICEF United Nations Children’s Fund USAID United States Agency for International Development VUP Large social protection programme WFP World Food Programme WHO World Health Organisation WIF Women Investment Fund xi Glossary of Key Terms 1st 1000 Days –The period from conception through 2 years of life [Pregnancy (270 days) + first year (365 Days) + second year (365 days)] when there is critical growth and development in a child and many health and nutrition interventions are highly beneficial and help prevent malnutrition including child stunting. Acute malnutrition –Also known as ‘wasting’, acute malnutrition is a condition characterized by a rapid deterioration in nutritional status over a short period of time. In children, acute malnutrition can be measured using the weight-for-height nutritional index or mid-upper arm circumference. Acute malnutrition is caused by a decrease in food consumption and/or illness resulting in sudden weight loss. Anaemia – a condition that arises due to reduced haemoglobin levels or red blood cells that impair the ability to supply oxygen to the body’s tissues. Anaemia is caused by inadequate intake and/or poor absorption of iron, folate, vitamin B12 and other nutrients. It is also caused by infectious diseases such as malaria, hookworm infestation and schistosomiasis; and genetic diseases. Women and children are high-risk populations. Clinical signs include fatigue, pallor (paleness), breathlessness and headaches fatigue, pallor (paleness), breathlessness and headaches. Chronic malnutrition – Chronic malnutrition or stunting, is a form of growth failure it is a condition defined as height for age below the fifth percentile on the WHO standard reference growth curve. Chronic malnutrition occurs over time, unlike acute malnutrition. Stunting starts before birth and is caused by poor maternal nutrition, poor feeding practices, poor food quality as well as frequent infections which can slow down growth. Community Growth monitoring and promotion (CGMP) – Individual-level assessment at community level where the growth of infants and young children is monitored by Community Health Workers in order to identify and address growth faltering and growth failure and promote and often demonstrate the services and practices needed to ensure adequate growth. Community-based management of acute malnutrition (CMAM) – This approach aims to maximize coverage and access of the population to treatment of severe acute malnutrition by providing timely detection and treatment of acute malnutrition through community outreach and outpatient services, with inpatient care reserved for more critical cases. Complementary feeding (CF) – Giving the infant and young other foods and fluids in addition to breast milk from the age of 6 months. The foods should be appropriate, adequate and safe. Continued breastfeeding – Continued breastfeeding refers to breastfeeding of children from 6 to 24 months or beyond in addition to providing other foods. It follows exclusive breastfeeding which starts from birth to 6 months. Exclusive breastfeeding – Is feeding of children from birth to 6 months with breast milk alone. During this period an infant receives only breast milk and no other liquids or solids, not even water, unless medically indicated. Food -- Food is any substance consumed to provide nutritional support for the body. xii Food security –Food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food that meet their dietary needs and food preferences for active and health life. Micronutrient powders (MNP) (Home fortification) – Addition of small, pre-packaged amounts of micronutrients powders to any semi-solid or solid food that is ready for consumption. This innovation is generally aimed at improving the micronutrient quality of nutritionally vulnerable groups, especially children between 6-24 months of age. Household Food Security (see Box 1) Iodine deficiency disorders – A range of abnormalities which result from iodine deficiency. In their most severe form, iodine deficiency disorders (IDD) include cretinism, stillbirth and miscarriage, and increase infant mortality. Even mild deficiency can cause a significant loss of learning ability about 13.5 intelligence quotient points at population level – as well as other symptoms such as goitre, an abnormal enlargement of the thyroid gland. It is especially damaging during the early stages of pregnancy and in early childhood. Low birth weight - Less than 2,500 grams. Low birth weight is often associated with stunting Micronutrient deficiencies -- Micronutrient deficiencies are a form of malnutrition caused by an insufficient uptake of vitamins and minerals (also known as micronutrients), which are essential for human health, growth and development. Among the more common forms of micronutrient deficiencies are Vitamin A Deficiency, Iron Deficiency (anaemia), and Iodine deficiency Middle Upper Arm Circumference (MUAC) - health workers to quickly determine if a patient is acutely malnourished. The measure is circumference of a patient’s arm at the midpoint between his or her shoulder and elbow. MUAC < 115 mm indicates that the child is severely malnourished; MUAC < 125 mm indicates that the child is moderately malnourished Severe acute malnutrition (SAM) – A result of recent (short-term) deficiency of protein, energy, and minerals and vitamins leading to severe loss of body fats and muscle tissues. Severe Acute Malnutrition (SAM) presents with wasting (low weight-for-height) and/or the presence of oedema (i.e., retention of water in body tissues). Defined for children aged 6–60 months, as a weight-for-height below 3 standard deviations from the median weight-for height for the standard reference population or a mid-upper arm circumference of less than MUAC < 115 mm indicates that the child is severely malnourished; MUAC < 125 mm indicates that the child is moderately malnourished. Small livestock – Animals which are considered not difficult to raise and provide animal sources food that can enhance household food security and good nutrition in the home (rabbits, chickens, ducks, pigeons, guinea fowls, quails, sheep and goats). Social Cluster Ministries - Rwanda’s Social Cluster Ministries include Ministry of Health (MINISANTE) Ministry of Agriculture and Animal Livestock Resources (MINAGRI), Ministry of Gender and Family Promotion (MIGEPROF), Ministry of Infrastructure (MININFRA), Ministry of Public Service and Labour MINFOTRA). Undernutrition – An insufficient intake and/or inadequate absorption of energy, protein or micronutrients that in turn leads to nutritional deficiency. xiii Underweight - Moderate and severe - below minus two standard deviations from median weight for age of reference population; severe - below minus three standard deviations from median weight for age of reference population. Wasting - Moderate and severe - below minus two standard deviations from median weight for height of reference population 1 EXECUTIVE SUMMARY This National Food and Nutrition Policy (NFNP) developed in 2013 builds on several achievements that have improved the status of nutrition and household food security in Rwanda during the past six years. The National Food and Nutrition Strategic Plan (NFNSP) 2013-2018, like the NFNP, outlines ambitious but necessary strategies needed to solve serious and persistent problems including the high prevalence of child stunting and high levels of anaemia in children and women. The NFNP and this NFNSP also take into account major differences in the economic development environment and the higher national and international priority placed on improving nutrition and related household food security problems in the second decade of the new millennium compared to 2007 when the country’s first National Nutrition Policy was adopted. National achievements since 2007 lower poverty levels, higher food production, and greater access to primary health care services for the rural poor and food and nutrition had gained prominence on the national development agenda as a prominent and foundational issue. In addition, by 2013 decentralization, performance based financing and good governance were defining national resource allocation and expenditure. The Millennium Development Goal regarding lowering the prevalence of underweight children was achieved. The NFNSP 2013-2018 outlines actions that address the most serious remaining problem regarding nutrition as presented in the NFNP. These include as the highest priority, the persistently high level chronic malnutrition in children under two years which is also noted specifically in the Economic Development and Poverty Reduction Strategy for 2013-2018 (EDPRS 2). The NFNP outlines key events and information sources that brought nutrition and household food security high on the national agenda. The NFNSP includes aspects of the NFNP situation analysis needed to justify the major strategic directions where actions are planned for the next five year period. Essentially, the NFNP foundation was built on key outcomes such as the Presidential Initiative to Eliminate Malnutrition (2009) RDHS (2010), the outcomes of two National Nutrition Summits (2009, 2011), the CFSVA/NS (2012), ), completion of health facility and community level tools to more effectively promote and counsel on Maternal, Infant and Young Child Nutrition (2011), development of the National multisector Strategy to Eliminate Malnutrition (NmSEM) (2010), a national Joint Action Plan (2012) to Eliminate Malnutrition (JAPEM) and District Plans to Eliminate Malnutrition (DPEM) in every district (2011). Other sources included relevant international and regional protocols and priorities, lessons learned on decentralized planning for nutrition improvement, and the progress and plans of several Social Cluster Ministries related to improving household food security and nutrition. Lessons learned included insight on the multisector characteristics of malnutrition prevention. Prevention of malnutrition must include decentralized ownership, multisector planning and collaborative execution of food and nutrition interventions. Also learned was that national 2 policies and strategies focused on nutrition and household food security were well aligned with the international Scale Up Nutrition movement. Both give priority and emphasis to the prevention of chronic malnutrition in children during the 1 st 1000 Day “window of opportunity” between the beginning of pregnancy and when the child reached two years of age. The NFNP situation analysis used by the NFNSP includes data to distil progress and remaining challenges in nutrition and household food security. As of 2010, stunting remained persistently high among children under five years (44%) and children 18-23 months (55%) with the multiple causal factors. 1 Access to nutritious food throughout the years remains a problem for 51% of Rwanda Families. 2 Only 22% of children between one and two years of age are given adequately nutritious diets. Stunting prevalence was shown to vary considerably by region with the highest rates in the northwest and west and the lowest rates in urban areas of Kigali. As measured by too thin for height (wasting, the prevalence of severe and moderate acute malnutrition among children under five years of age was found to be low prevalence (3%), Underweight children (too thin for age) 3 Are 11% but this is much lower than in 2005 (18%) and this positive trend appears to be continuing. Anaemia prevalence among children dropped from 52% in 2005 to 38% in 2010 but this is still high and among children 6 months to one year of age, seven out of ten are suffering from anaemia. Among pregnant women, (20%) are found anaemic. 4 Maternal overall nutrition requires improvement with 7% of women found to be too thin and 16% overweight or obese (30% in Kigali). The prevalence rates of infectious diseases among children have all decreased substantially in recent years, and prevention of parent to child transmission of HIV has been reduced. These areas of progress remain limited by poor complementary feeding practices (6-24 months) that accompany continued breastfeeding. The linkage between nutrition and household food security is made clear and actionable in the NFNSP because of documentation through the CFSVA/NS (2012) identified serious remaining challenges in assuring the appropriate food is accessible to and used by all families and age groups in ways that result in good health and nutrition. More than 50% of families surveyed were found to have problem with food access at different times of the year and 78% of children 6-23 months received food that was not satisfactory in terms of nutrients. For vulnerable groups additional problems remain. For example nutrition and food security 1 RDHS 2010. Similar prevalence levels were found in the CFSVA/NS in 2012. 2 CFSVA/NS 2012. 3 RDHS, 2010. 4 RHDS. 2010. 3 problems for PLHA are complicated by compromised immune systems, frequent membership among the most vulnerable classes, stigma and incomplete families. Data used in the situation analysis of the NFNP also revealed that Rwanda is now facing the double burden that comes from continued under-nutrition and increasing over-nutrition and related chronic diseases. In general, data reviewed and other information shows the situation of child stunting in 2013 remained serious with the highest rates (58%) among children 6-18 months of age. Almost 15% were found to be stunted at two months which indicates a poor growth of the foetus during pregnancy. Also found were major variation in stunting rates and food accessibility with the greatest problems in the northwest and western areas and the least problems in urban centres. Recognition of child stunting as a national nutrition, food security and social protection problem is reflected in the priority given to lowering its prevalence in EDPRS 2, HSSP III and the NFNP and also in this National Food and Nutrition Strategic Plan 2013 2018 (NFNSP). The vision and mission of the NFNP remain the same as in 2007. The strategic approach was modified to be more effective given the current situation, the Social Cluster Ministries nutrition and household food security related policies, plans, priorities, EDPRS 2, international linkage and resources mobilization potentials from sector budgets, development partners, and districts. The NFNP and NFNSP use a conceptual framework adapted from the Health Sector Strategic Plan III. This includes multisector ownership, responsibilities, and joint participation, foundational principles lined to good governance and national and international policy linkages and seven strategic directions. Two are multisector, four are more sector-specific, and one covers governance, supporting services, capacity building, communication support, monitoring and evaluation and related activities. Strategic Direction 1 has the objective of sustaining the position of food and nutrition as central priorities of the Government across Sectors at all levels and among Development Partners. It focuses on advocacy and resource mobilisation. It includes and has a priority the objective of assuring that the high level of commitment and the national priority given to solving problems of food and nutrition is sustained. This includes but goes well beyond broad and effective dissemination of the NFNP. Strategic Direction 2 has the objective of preventing stunting in children under two years of age. This requires multisector joint support and coordination at national, district and community levels; It recommends on-going national level promotion of the 1st 1000 Days and that districts strengthen District Plans to Eliminate Malnutrition. The NFNSP calls for greater emphasis be given to prevention of stunting and that these plans be integrated into District Development Plans. This Strategic Direction requires strengthening of regular community-based activities that have been centred on growth monitoring. The result should be 1 st 1000 Days Community Based Food and Nutrition Programs (CBF&NP) that effectively balance anthropometric 4 assessment of children with a wide range of promotional and instructive activities. These strengthened community based nutrition programmes are needed in each umudugudu. They need to be facilitated by not only Community Health Workers (CHWs) but also by front line workers from the agriculture sector and those from MINALOC working with protection services and early childhood development. These strengthened, community owned programmes need to expand participation to include all pregnant women as well as mothers, caregivers and families with children under two years (as well as others with children 2-5 years). These 1 st 1000 Days CBF&NP will also place special emphasis on women and children in the most vulnerable families. These 1 st 1000 Days CBF&NP programmes should include promotion and activities linked with the wide range of key services and practices that can help enhance household food security, protect maternal health and foetal growth during pregnancy and prevent stunting during a child’s first two years. These programmes should also bring important knowledge and skills and promote key services to the most vulnerable families in the community. Strategic Directions 3, has the objective of strengthening, expanding and promoting services and practices that result in household food security year round. It seeks to improve the linkage between household food security and healthy nutrition of each household’s children and women. It incorporates the MINAGRI Nutrition Action Plan (NAP) (2013) into the NFNP. The five interventions areas of the NAP and corresponding sets of interventions that cover the main NAP strategic objectives. The objectives focus on improving access and use of nutritious foods at household level. The interventions called for are to be linked with the most vulnerable households. Expanding to some extent on the NAC interventions, NFNP Strategic Direction 3 also recommends synergy between these interventions and the 1 st 1000 Days CBF&NP of Strategic Direction 2. Strategic Direction 4 has the objective of prevent and manage all forms of malnutrition. This objective is linked to several specific intervention areas that are within the MINISANTE mandate of preventing and managing all forms of malnutrition. Many of the areas covered can be cross referenced with the Health Sector Strategic Plan III 2012-2017. They include maintaining current levels of active identification and management of acute malnutrition, improving MIYCN, increasing efforts to prevention and control of micronutrient deficiencies including deficiencies in Vitamin A, Iron and folic acid and iodine. This strategic direction also has the objective of further strengthening programmes to improve nutrition and HIV/AIDS, and to improving hygiene and sanitation. A final objective is to increase knowledge around problems of nutrition-related non-communicable diseases and develop and strengthen strategies to address these. Operational linkage between these areas of interventions and other Strategic Directions are recommended and will be necessary for successful implementation of the NFNP. Strategic Direction 5 has the objective of strengthen nutrition education in schools through curricular and extracurricular activities. This objective is linked with and supports the food and nutrition elements of the MINEDUC School Health Policy. These include moving 5 forward in implementing school feeding through the Home Grown School Feeding Programme, improving food and nutrition learning in schools and expanding school based health and nutrition assessment and services. More specifically, the NFNP recommends implementation of the “home grown school feeding programme” and continuation of efforts to bring milk to more young children. Improving nutrition and food security learning is recommended through strengthening the curriculum and extracurricular activities including the use of gardening and small livestock as teaching learning resources. In correspondence with the MINEDUC School Health Policy regular nutrition assessments are recommended as part of health assessments as well as activities including deworming and Vitamin A supplementation in collaboration with the MINISANTE. Strategic Direction 6 has the objectives strengthen emergency preparedness and response in areas of nutrition and food security of families and individuals and response to natural disasters and in refugee situations. While this area had not been broadly specified as yet by MIDIMAR, it is included in the NFNP in order to promote its importance. The NFNP aims to bring forward and promote appropriate food and nutrition related details in policies and strategies that are more explicitly developed by MIDIMAR and its operational and implementing partners. Strategic Direction 7 has the objective of improve governance systems and accountability (planning, budget allocation, implementation and monitoring and evaluation) for nutrition and food security. This strategic direction as multiple components that focus on assuring support for the overall policy the range of supportive services needed to effectively implement NFNP objectives and sustain them. This strategic direction also has the objectives of mobilizing resources from within participating sectors, and promoting additional activities that cut across sectors. These include, planning, monitoring and communication support. Also addressed are the need to move forward in critical areas such as nutrition capacity building and better systems for regular sharing of useful operational information including lessons learned across sectors at national provincial and district levels. Implementation plans and priorities are provided in brief for each of the strategic directions in the NFNSP 2013-2018 and a the table recommending national and decentralized roles and responsibilities each Government of Rwanda body as well as Development Partners, and NGOs and the private sectors are describes Recommendations for monitoring in the NFNSP take into account the multisector approach of the NFNSP and call for the use of data from monitoring and information management systems of MINISANTE, MINAGRI, MINALOC and MIDGEPROF. Also to be used are selected data from national surveys and nutrition and food surveillance. Combined these data will help districts and sectors to develop and adjust multiyear and annual targets for reporting and also for innovative multisector data displays of key indicators against targets that will be developed and used to track progress and make adjustments national, district and sector levels and in some communities. The NFNSP also describes other monitoring and reporting inputs that include periodic reviews of progress on strategic directions by sector and 6 multisector led teams and the use of data from key national and district level surveys and analyses. The nutrition indicators introduced into RapidSMS systems are viewed as an important information source. Multisector input into overall DPEM monitoring is recommended to guide adjustment of support for the 1 st 1000 Days CBF&NP. New and stronger systems to generate, gather, organize and share useful operational information and lessons learned are outlined as well. The NFNSP draws from the NFNP to provide guidance on mechanisms to strengthen leadership and coordination that is needed to assist implementation in the context of broadened policy ownership by MINALOC, MINISANTE and MINAGRI. These mechanisms will allow multisector and joint sector planning and policy implementation at national and decentralized levels. The NFNP includes recommendations for an approach to mobilize the needed resources to implement the policy. The NFNSP concludes with a multisector monitoring and evaluation framework that draws from sources noted above and initial estimates of costs and sources of funds. In most cases, activities, funding and personnel resources are cross referenced against the sector specific strategies that have been adapted by the NFNP and NFNSP. In this way, synergy is generated and new coast are kept to a minimum during the five year period. As noted in the NFNP, an environment of opportunity is present for successful achievement of the ambitious food and nutrition objectives set in the EDPRS 2, and also to better implement relevant sector policies as well as the ambitious additional objectives of this five year strategic plan. Many of the conditions need to improve nutrition toward an optimal state for different groups are present including a high level of political commitment, and substantial resources Many of the immediate and underlying causes of malnutrition, and particularly the high prevalence of stunting among children under two years of age, are addressed in current plans of Social Sector Ministries and in this NFNSP. NFNSP outcomes are expected to be multiplied by existing commitment within the Social Cluster Ministries and across Government to participate in coordinated joint sector and multisector planning and activities. The NFNSP concludes that the potential of active community ownership and participation in activities surrounding food and nutrition has been well demonstrated in Rwanda. These characteristics should be easily sustainable because they remain central as community based activities moves toward a stronger focus on the prevention of chronic malnutrition while continuing place priority on actively identifying and managing acute malnutrition among young children. Community based activities are expected to gain additional participation and power as more sectors become actively involved in food and nutrition district planning and multisector facilitation in communities. These efforts should be boosted further by the on going national promotion activities of the 1 st 1000 Days in the Land of 1000 Hills Campaign. 7 In this environment of opportunities, the NFNSP will move NFNP implementation steadily toward reducing and preventing malnutrition in children and toward the overall goal of improving household food security and the nutritional status of the Rwandan people. 8 1. NFNP Rationale and Scope of the NFNP and NFNSP 2013-2019 Background This National Food and Nutrition Policy (NFNP), developed in 2013, is an updated revision of the National Nutrition Policy of 2007. The National Food and Nutrition Strategic Plan 2013-2018 is the first multisector strategic plan based on that revised policy The NFNP provides describes the current situation and key trends as well as the challenges and opportunities related to nutrition and household food security in Rwanda. The NFNP retains close linkage to Rwanda VISION 2020, the Millennium Development Goals and provides an up to date policy base for nutrition and household food security actions that takes into account national progress and challenges. The NFNP aligns with the EDPRS 2, sector and subsector policies and strategic plans. The policy emphasizes the importance of food and nutrition during pregnancy and the first two years of a child’s life in order to better assure normal growth both during the gestational period and as the young child rapidly develops. When chronic malnutrition, as measured by a child’s length for age, occurs during this period, the negative impact is permanent, often resulting in less than optimum health, cognitive and social development and productivity throughout the lifespan. The NFNP recognize that food and nutrition are important to prevent illness, assisting in recovery from infection and to increase the efficacy of medications including antiretroviral drugs. Food and nutrition plays a critical role in prevention, treatment and care of HIV/AIDS. The linkage of food and nutrition to productivity and economic development also underlies the importance of the NFNP. The Social Cluster Ministries5 decided the updated policy would be named “National Food and Nutrition Policy.” This recognizes the close link of adequate nutrition with adequate household food security. The multisector nature of the NFNP is explicitly recognized though joint ownership by the Ministry of Health (MINISANTE), the Ministry of Agriculture and Livestock Resources (MINAGRI) and the Ministry of Local Government (MINALOC). Participation and implementation responsibilities of other Ministries and stakeholders are necessary at both national and decentralized levels. The NFNP development and drafting process was coordinated by the Maternal and Child Health Department (MCH) of MINISANTE in close consultation with focal points for food and nutrition in each Social Cluster Ministry. Development partners provided technical 5 The Social Cluster Ministries include Ministry of Health (MINISANTE) Ministry of Agriculture and Livestock Resources (MINAGRI), Ministry of Gender and Family Promotion (MIGEPROF), Ministry of Infrastructure (MININFRA), Ministry of Public Service and Labour MINFOTRA). 9 assistance and funding for many of the consultative meetings.6 Desk research used background documents, national surveys and studies, national and international guidelines and relevant scientific studies. The National Food and Nutrition Technical Working Group (NF&NTWG) assisted with and reviewed the NFNP rationale, outline, conceptual framework and proposed strategic priorities and directions. The NF&NTWG outlined NFNP sector specific and multisector strategic directions and intervention packages and an appropriate coordination framework for implementation. On-going consultations were held with technical personnel in the Social Cluster Ministries and Development Partners. Among these were MINISANTE, MINAGRI, MINEDUC, MIDIMAR, MINALOC and MIGEPROF as well WFP, UNICEF, WHO USAID, the EU and others. A major source of decentralized input and participation came from a two day workshop with cross sector teams from all 30 Districts led by District Planning Officers. District personnel provided essential information and advice based on achievements and constraints encountered during past and current food and nutrition strategies and programmes at district and village levels. The draft NFNP was validated during a NF&NTWG workshop that also assisted in developing the logical frameworks for the National Food and Nutrition Strategic Plan NFNSP (2013-2018). The NFNP draft was submitted to the Social Cluster Ministries for review before forwarding to the Cabinet of Ministers for approval. Based on this process, the NFNP broadens emphasis on multisector participation and responsibilities. The revised conceptual framework includes seven strategic directions that address major food and nutrition problems facing the country in the second decade of the millennium. The multisector and sector-specific strategic directions are intended to both sustain significant progress and address serious on-going food and nutrition problems including child stunting. If followed, with commitment these strategic directions will help to reduce child stunting as called for in the EDPRS 2. Four NFNP strategic directions focus on specific Ministries responsibilities in the areas of food and nutrition. These include MINAGRI, MINISANTE, MINEDUC, and MIDIMAR. Two strategic directions focus on fully multisector approaches with joint activities and shared responsibilities. The final strategic direction addresses the major support services, plans and activities needed to support food and nutrition as a multisector endeavour and to sustain long terms achievements in food and nutrition that are expected to occur. If followed, the strategic directions of the NFNP will help to reduce child stunting. The NFNP enhances the overall food and nutrition policy base thereby providing the advocacy tool needed both within and across sectors to achieve and sustain the food and nutrition objectives of the Millennium Development Goals, Rwanda Vision 2020 and EDPRS 2. 6 Partner funding and technical assistance were provided primarily from the World, Food Programme, UNICEF and WHO. The REACH Project facilitated many key activities. 10 The NFNP also outlines innovative and potentially more effective approaches to monitoring and information sharing to be used to adjust existing programmes and strategies toward greater multiple sector participation. Combined with NGO participation and community ownership, such approaches should provide the resources needed. The NFNP and the NFNSP clearly accepts that a high degree of cross sector responsibility, coordinated cooperation and active collaboration by multiple sectors and development partners is needed to solve problems of household food and poor nutrition in many households. Pragmatic coordination structures within Government are outlined for both national and decentralized levels. This approach is expected to generate a synergy of services, expertise, and promotions that can facilitate the multiple actions required to substantially reducing stunting in children under two years of age and solve other nutrition and household food security problems. Further illustrating the need for a broad scope Social Cluster Ministries decided to expand the name beyond the 2007 “National Nutrition Policy” to the “National Food and Nutrition Policy” for the update. One basis for this decision was the essential linkage of household food security to healthy nutrition. (See Box 1). The name change also reflects the EDPRS 2 inclusion of “food and nutrition” as a foundational issue of Rwanda’s national development. While the NFNP and the NFNSP have broad scope it does not extend into areas such as agricultural staples production or most other areas of the Ministry of Agriculture and Animal Resources’ “Strategic Plan for the Transformation of Agriculture III, It does seek to reinforce elements and integrate the MINAGRI enhanced efforts to improve household food security, particularly as outlined in the MINAGRIC “Nutrition Action Plan” (2013). The scope of the NFNP is also reflected in the decision of the Social Cluster Ministries to expand the policy’s ownership to include the Ministry of Health (MINISANTE) the Ministry of Agriculture and Animal Resources (MINAGRI) and the Ministry of Local Government (MINALOC). This co ownership recognize the essential roles of all Box 1: Food Security, Household Food Security and Nutrition National Food and Nutrition Policy views “Food Security” in terms of the World Food Summit in 1996 definition that is that food security exists when all people, at all times, have physical and economic access to sufficient safe and nutritious food to meet their dietary needs and food preferences for a healthy and active life (World Food Summit 1996). Household’s food security exists when members of the household have the ability to be food secure. Both long term and seasonal household food insecurity can negatively affect the health of family members and particularly women and young children. Poor nutrition can occur despite household food security in the following circumstances: 1. A household’s the ability to acquire enough food is not converted into actual food acquisition 2. A household that resources for enough food uses them to acquire other goods and services (school fees, housing etc.) 3. Allocation of the food within the household does not take into account the needs each member. Finally, individual food security resulting in good nutrition also depends on non-food factors such 11 three Ministries in successful implementation of the NFNP at both national and decentralised levels. The NFNP and the NFNSP broaden the emphasis on multisector participation and responsibilities. The revised conceptual framework hey use includes seven strategic directions that address major food and nutrition problems facing the country in the second decade of the millennium. The multisector and sector-specific strategic directions are intended to both sustain significant progress and address serious on-going food and nutrition problems including child stunting. If followed, with commitment these strategic directions will help to reduce child stunting as called for in the EDPRS 2. Two strategic directions focus on fully multisector approaches with joint activities and shared responsibilities. The final strategic direction addresses the major support services, plans and activities needed to support food and nutrition as a multisector endeavour and to sustain long terms achievements in food and nutrition that are expected to occur. If followed the strategic directions of the NFNP will help to reduce in child stunting Four NFNP strategic directions focus on specific Ministries responsibilities in the areas of food and nutrition. These include MINAGRI, MINISANTE, MINEDUC, and MIDIMAR. The broaden scope of the updated NFNP enhances the policy base for the NFNSP and should serve as advocacy tool needed both within and across sectors that is needed to achieve and sustain the food and nutrition objectives of the Millennium Development Goals, Rwanda Vision 2020 and EDPRS 2. The NFNP also outlines innovative and potentially more effective approaches to monitoring and information sharing to be used to adjust existing programmes and strategies toward greater multiple sector participation. These are each put into operation in the NFNSP. Combined with NGO participation and community ownership, such approaches should provide the resources needed. The NFNP clearly accepts that a high degree of cross sector responsibility, coordinated cooperation and active collaboration by multiple sectors and development partners is needed to solve problems of household food and poor nutrition in many households. Pragmatic coordination structures within Government are outlined for both national and decentralised levels. This approach is expected to generate a synergy of services, expertise, and promotion that can facilitate the multiple actions required to substantially reducing stunting in children under two years of age and solve other nutrition and household food security problems. The NFNSP 2013-2018 lays out the means by which this approach can be effectively implemented. The linkage of the NFNP to other National and International Policies and Policy level documents 12 Rwanda VISION 20/20 The updated NFNP fully corresponds with Rwanda’s VISION 2020. The principle objective of reducing acute malnutrition in children to below 20% by 2010 and 2020 target of 10% were achieved by 2013. The NFNP is guided by the VISION 2020 “roadmap” by linking to sector strategies and a major effort to integrate key food security and nutrition strategies and programmes into District Development Plans. Economic Development and Poverty Reduction Strategy 2 The NFNP link to EDPRS 2 that clearly recognized that despite major economic and poverty reduction progress, improvements in nutrition and household food security remains a “foundational issue.” Specifically, regarding chronic malnutrition in children, EDPRS 2 notes research studies that estimate malnourished children risk losing 10% of their lifetime earning potential and that the physical and mental damage associated with poor fetal growth and stunting are irreversible after the age of two.7 Malnutrition can cause countries to lose up to 3% of GDP. EDPRS 2 also recognized that interventions and services to prevent and minimize the impact of chronic malnutrition begin at conception and continue until the child is two years old.”8 The EDPRS 2 concludes that reducing Rwanda’s chronic malnutrition rates for children under two years of age is an important national development objective. Health Sector Strategic Plan III The development of the NFNP and National Food and Nutrition Strategy Plan (NFNSP 2013 2018) are priorities of the Health Sector Strategic Plan III (2012-2018). HSSP III recognizes the substantial progress made in the nutrition sector during the five year 2009 2013. The HSSP III states that food supplements and food are primary “medicines” used to prevent malnutrition and the importance of linking social protection with food and nutrition to better assure access to key health services and food for the most vulnerable groups. The HSSP III provides nutrition improvement targets adopted by the NFNP. These include reductions in underweight from 11% to 6% and in stunting from 44% to 24.5% among children under two years of age by 2018.9 Linkage with other GOR Sector Policies and Strategies Household food security is an integral element of the NFNP and both the policy and NFNSP draw substantially from the MINAGRI Strategic Plan for the Transformation of Agriculture Phase III and the MINAGRI Nutrition Action Plan (NAP) (2013-2018). The 7 EDPRS 2, GOR 2013. 8 EDPRS 2, GOR, 2013. 9 HSSP III, MINISANTE, GOR, 2012. 13 NFNP and the NFNSP build on the MINAGRI NAP that aims principally at improving household food security, particularly in districts where food access throughout the years is lowest and for the most vulnerable groups. The NFNP also recognizes national efforts to shift away from purely subsistence agriculture toward more knowledge-intensive, market-oriented approaches for the small farmer. Other Government policies integrated with the NFNP are the (MINEDUC) School Health Policy (2013 draft), MINALOC National Social Protection Strategy (2011), MININFRA, National Policy and Strategy for Water Supply and Sanitation Services (2010), MIGEPROF National Policy for Family (2005), the National Policy for Gender (2010), National Strategic Plan for Fighting Against Gender-Based Violence (2012), and the (MADMAN) National Disaster Management Plan (2012). These sector policies reinforce the key linkages among nutrition, household food security, social protection, education, safe water, hygiene and sanitation, gender, and family issues. Global and Regional Conventions The NFNP incorporates major elements from global and regional conventions and guidelines that deal with direct and underlying principles related to nutrition and household food security. These include the 1990 World Summit for Children, the World Health Assembly (1991), International Conference for Nutrition (1992) and the World Nutrition Summit (1996), which each influenced nutrition becoming an integral part of the Millennium Development Goals. The NFNP also recognizes Rwanda ratification of the Convention on the Rights of the Child (CRC) and Convention for the Eradication of all forms of Discrimination against Women (CEDAW) that include important principles on food production (labour), household food security, and nutrition (intra-household distribution). At regional level, the NFNP accepts key resolutions related to nutrition and household food security from of the e Comprehensive Africa Agriculture Development Programme (CAADP), the African Union New Partnership for Africa’s Development (NEPAD) and the Agriculture and Rural Development Strategy for the East African Community. The NFNP also draws from the international Scale Up Nutrition (SUN) movement that was initiated in 2010 to promote and guide national efforts to improve nutrition and mobilize national and international resources. The international priority for improving nutrition was strengthened in 2008 after research showed that high malnutrition and particularly chronic malnutrition among young children had lifelong negative effects on the child and on national economies. Research also showed that effective use of a package of existing, low cost, interventions could reduce chronic malnutrition among children. The NFNP also recognizes coordinates efforts by the UN System in Rwanda through the REACH Programme to support planning and advocacy surrounding nutrition and household food security. Rwanda officially recognition as a “SUN” country provided the NFNP with a broader support base for implementation as development partners have stepped in with added assistance. The NFNP was also informed by the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition endorsed by the WHO World Health Assembly in 2012. 14 Situation Analysis Factors leading to revisions in the NFNP and NFNSP 2013-2018 National Nutrition Policy 2007 The NFNP has major roots that extend back to the 2007 National Nutrition Policy. At that time the incidence of severe acute malnutrition was high, food production was not progressing, and misdistribution of food was common at each administrative level. Household food insecurity was very high, access to health services was low and the HIV/AIDS pandemic had only begun to come under control. Household purchasing power was poor and ignorance was common around many nutrition practices needed for good health of young children, pregnant women, the elderly, and other vulnerable groups. To address that difficult environment and provide a policy base for the future, the NNP of 2007 outlined a sector-wide approach focused primarily on lowering the prevalence of acute malnutrition among children and reducing micronutrient deficiencies (MND) among women and children less than five years of age. The 2007 NNP also called for development and adoption of protocols for managing malnutrition, promotion of optimal infant and young child feeding (IYCN) and scaling up of community based nutrition programmes (CBNP) in every district. It also proposed national supplies of therapeutic food products for acute malnutrition, and expansion of micronutrient fortified staples and special food products to use in emergencies and food programmes supplementing most vulnerable including those infected and affected by HIV/AIDS. Other 2007 NNP priorities included fortification of staples and vitamin and mineral supplementation targeted to specific young children and pregnant women, expanding food in schools and opening of school canteens and addressing the nutrition-infection synergy in schools through better sanitation and de-worming. The NNP recognized that many nutrition problems had their causes rooted in poor household practices and included a strategy using communication to promote nutrition practices including improved complementary feeding, exclusive breastfeeding, more diverse family meals and better hygiene and food safety practises. 15 Box 2: President’s Initiative to Eliminate Malnutrition (2009) Led by the Ministry of Local Government with technical leadership by the MINISANTE, more than 30,000 Community Health Workers (CHWs) were trained over a two month period in 2009 to carry out community level actions outlined in the National Protocol for the Management of Malnutrition. Over five months CHWs used MUAC tapes to screen more than 1.3 million children. Of these, more than 65,000 were referred and treated for moderate or severe acute malnutrition. The successful implementation of this initiative demonstrated that active and coordinated multisector participation was possible and could successful address a serious problem affecting communities and families across the country. The PIEM also demonstrated donors’ interest and willingness to reallocate or provide additional funding for well-targeted activities that reduced childhood nutrition. The NNP proposed significant involvement from all sectors and called for decentralized programmes and interventions that were to be implemented mainly through clinics and community-based nutrition programmes. Strategies also aimed at further building Government commitment to nutrition, its integration into the first Economic Development and Poverty Reduction Strategy (2008-2012) and mobilizing increased resources from Government and Development Partners. The NNP of 2007 recognized the strong need for building capacity through training and assigning more nutritionists at district and national levels. The strategic areas outlined that policy document also served as a principle starting point for revised and updated section of the National Food and Nutrition Policy and the NFNSP 2013 2018 .The substantial differences in the updated and revised policy and strategic plan come from a review of several factors including changes in the national development priority given to nutrition and household food security. The major elements that have contributed to the strategic directions of the NFNP and the NFNSP 2013-2018 are outlined in the sections that follow. Political context and key events leading to NFNP update and revision A highly significant change that led to a new intervention strategy at national scale originated with a Presidential call in April 2009 for greater priority and more effective actions to be taken to eliminate serious acute malnutrition problems of vulnerable groups. 16 The President’s public commitment and request for more effective actions by Government sectors brought urgency and a higher level of commitment to combat acute malnutrition in children at each administrative level. A positive donor response also came and a genuine multisector effort was rapidly planned and successfully implemented that year. That national effort, originally called the National Emergency Plan to Eliminate Malnutrition, later became known as the President’s Initiative to Eliminate Malnutrition10 (PIEM). (See Box 2) National Nutrition Summits Another major factor that changed the situation was the first and second National Nutrition Summits. The first, held in November 2009 shortly following the PIEM, served as pragmatic review of achievements and remaining major nutrition challenges. (See Box 3) The Consensus Statement of that First National Nutrition Summit included many useful recommendations that were accepted by the Ministry of Health. Two of these were: (1) activities similar to those carried out in 2009 to actively identify and effectively treat cases of acute malnutrition should be continued and (2) much higher priority should be given to prevention of acute and chronic malnutrition in children. National multisector Strategy to Eliminate Malnutrition (NmSEM) and District Plans to Eliminate Malnutrition 10 Rwanda Economic Development and Poverty Reduction Strategy 2 (EDPRS 2). Box 3: First National Nutrition Summit (2009) Leaders from the social Cluster Ministries, experts and academicians, researchers, teams from the districts partners and NGOs participated along with national and international scientists and academics. Presentation and discussions focused on Rwanda’s major nutrition problems. There was recognition that many effective projects were going on at district and lower levels but that these needed to be scaled up. Presentations also include international research summaries focused on the negative impact of child stunting on the child and collectively on national economic development were complemented by others that highlighted evidence-based intervention set that can help prevent chronic malnutrition. Discussions coalesced around the persistently high prevalence of stunting among children and the immense individual, family and national consequences of chronic malnutrition in children. The 1st National Nutrition Summit Consensus Statement, while not an official policy source, outlined the major nutrition and household food security challenges facing the country at the end of 2009 and well-reasoned recommendations for priority actions. It was endorsed by the MINISANTE and fed into subsequent national nutrition strategy development. 17 In 2010, three year after the NNP was adopted, a National multisector Strategy to Eliminate Malnutrition 2010-2013 (NmSEM) was developed to guide more systematic implementation. That strategic plan placed major priority on the 2007 NNP foundational issue of decentralized approach and multisector involvement. This resulted in development of District Plans to Eliminate Malnutrition (DPEM). These DPEM were to give priority for stunting prevention while continuing to promote active identification of acute cases of malnutrition, improve micronutrient nutrition, and promote MIYCN as well as other policy priorities. In 2011, the Second National Nutrition Summit was held and focused on the challenges faced in planning DPEM and mobilizing resources needed to implement and monitor them in cases where partner funds were not available. (See Box 4) , The I third National Food and Nutrition Summit was held in February 2014). That meeting focused primarily on the 1 st 1000 Days, and the Strategic Direction of the NFNP and NFNSP 2013-2018 A Joint Action Plan for the Elimination of Malnutrition, (JAPEM A Joint Action Plan for the Elimination of Malnutrition (JAPEM) was set up by the Social Cluster Ministries to provide multisector support and monitor the NmSEM and DPEM implementation. A review by the JAPEM in 2012, found that few districts achieved the level of multisector commitment needed to effectively support full implementation of the DPEM. EDPRS 2 foundational issue of food and nutrition and prevention of child stunting Food and nutrition was made a foundational issue in the EDPRS 2 (2013-2018) and the national plan specifically stated the need to reduce stunting in children and gave emphasis on the 1st 1000 days beginning at conception and continuing until a child reached two years. The need to effectively target agriculture programmes related to household food security and the most vulnerable groups was also called for. The prevention of child stunting was further elevated as it became the focus of a national communication and promotional campaign, “1st 1000 Days in the Land of 1000 Hills,” launched by the Prime Minister in 2013. Box 4: Second National Nutrition Summit (2011) A second National Nutrition Summit team presentations clarified the potentials, constraints, November 2011, had participation from every district, and national and international levels brought renewed emphasis on the importance of preventing child stunting. There was also a presentation on a powerful, rapidly coalescing, international movement known as “Scaling up Nutrition” (SUN) dedicated to supporting national commitments to prevent chronic malnutrition in young children in countries where stunting rates among this age group were high. The SUN Movement was accompanied by an international advocacy initiative name “1000 Days.” The district commitment, coordination, and resources needed for effective decentralized plans and broad scale community-based efforts in nutrition. A common constraint was the broad focus of the DPEM not only on acute and chronic malnutrition but also many other major strategies in the 2007 policy and NmSEM. 18 The strategic directions and objectives that surround chronic malnutrition in the NFNP and NFNSP 2013-2018 were informed by these national actions, strategies and decentralized efforts nationwide. The result is a strategic plan that will continue to actively identify and effectively manage cases of acute malnutrition while strengthening multisector district plans and community based programmes aimed toward the prevention of stunting in children under two years of age. Additional strategic directions address household food security, prevention and management of all forms of malnutrition, food and nutrition in schools and in preparing for emergencies. Malnutrition and related factors in Rwanda: trends, progress and gaps Multiple Conditions affecting Optimal Nutrition Obtaining and sustaining optimal nutrition in Rwanda follows a model that includes three levels of causal factors: immediate, underlying, and basic causes. Optimal is complicated by the fact that individual needs for various nutrients change throughout the lifecycle. In addition to complexities with required food intake, disease prevention is second immediate challenge because illness affects both appetite and nutrient absorption and nutrition affects immunity. Therefore, prevention of infection and proper feeding of the sick child may be as important to achieving optimal nutrition as the adequacy of food. (See Figure 1).11 In Rwanda, economic growth and improvements in rural and urban incomes have improved conditions needed for optimal nutrition at basic levels. There also have been higher levels of political commitment, major increases in resources allocated to basic services, and continually improving infrastructures. Underlying conditions have also improved including greater access to health care (including health insurance). As a result, trends in infectious disease are substantially lower and the synergy between disease and optimal nutrition has been weakened. Social protection services have improved and expanded but many remain limited in terms of coverage. Education is expanding in terms of overall access and gender parity. While many of the underlying 11 Figure 1 is adapted from several models of the causes of malnutrition and Household Food Security including those developed by WHO, UNICEF and WFP. Figure 1: Conditions Affecting Optimal Nutrition 19 condition needed to prevent disease and support adequate nutrient intake have improved, there remain serious challenges. This is shown clearly by the high level of chronic malnutrition that remains, the high levels of households without adequate food throughout the year. There are also seriously low levels of micronutrients and for many children from 6-24 months of age there are too few nutrients. As a result, an adequate intake of nutrients is not achieved by many women and children and especially for the most vulnerable. These problems are well recognized but there are no simple solutions to many of them. Additional details on these conditions and related trends are provided in the sections that follow. Acute malnutrition Acute malnutrition, measured in terms of wasting (too thin for height), and underweight (too thin for their age) can result from a situation where food supplies are cut. In other circumstances acute malnutrition often results from incorrect breastfeeding practices, or poor complementary feeding often linked to illness such as diarrhoea, acute respiratory infection or malaria. Underweight prevalence for children under five years of age in Rwanda was 3.6% nationally in 2012. The prevalence was 12% for children 6-12 months. This is a critical six month period when, in addition to continued breastfeeding, frequent complementary feeding of small portions of calorie dense foods is needed. Also during this period, children need careful hygiene to avoid faecal oral disease transmission, continued use of treated bednets to avoid malaria, and other preventive services including vaccinations. Cases of both moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) in Rwanda have been better managed since dissemination of the National Protocol for Management of Malnutrition during the PIEM in 2009 and more actively identified early since that time. Capacity building around the national protocol is needed at all levels of the health systems. The supply and logistic issues related to well-planned procurement, distribution and use of therapeutic foods for SAM management and supplementary food to support MAM management can be improved. In addition, the prevention of acute malnutrition needs to be better balanced against actions to identify cases early and manage them well. Without this effort, cases will continue to occur and those that have been treated effectively may return with similar conditions. Chronic malnutrition Chronic malnutrition is measured in terms of length for age. Chronic malnutrition or “stunting” can occur during gestation when a woman does not have adequate food and care during pregnancy. Stunting may also occur during early childhood if a child suffers from serious or frequent acute malnutrition, is frequently ill or has poor infant and young child feeding and care. 20 In Rwanda the prevalence of stunting prevalence among children under five years had decreased from 51% in 2005 to 44% in 2010 but has stayed almost the same at 43% in 2012. However, as noted previously, the impact of stunting is permanent for children under two years and the rate of chronic malnutrition in children 18-23 months of age was 55% in 2010. (See Figure 2). Causes behind this high prevalence are not fully known. The rate of about 15% at two months likely indicates stunting at birth which is attributable mainly to inadequate nutrition of the mother or serious illness during pregnancy. After birth, exclusive breastfeeding rates are high and breastfeeding most often continues throughout the first 24 months of life or beyond often beyond. The period when stunting is found to rapidly increase, directly corresponds with the period when complementary foods are introduced and also when the infant starts to become more active and exposed to infectious disease. Information from qualitative studies and national surveys have found that many children are not fed in accordance with requirements and recommendations in terms of the adequacy of the nutrients or the frequency needed because their stomachs are small. 12 Maternal, Infant, Young Child and Nutrition (MIYCN) Despite a major programme to improve maternal, infant and young child nutrition mainly through activities at clinics and by in communities by CHWs, serious problems remained in 2013. While breastfeeding rates are very high throughout the country, complementary feeding was found to be inadequate for many infants over six months and children under two years in many households. The direct conditions requiring improvement were the amounts and quality complementary foods and the frequency of feeding. Underlying these conditions are the need for more knowledge and skills on the parts of mothers and caregivers, inadequate household food security in some cases and problems such the mother not being able to stay with the child because of work. ‘ 12 CFSVA/NS (2012) and Survey Figure 2: Child stunting increases during complementary feeding period 21 As noted in the previous section, children need additional food to complement breastfeeding after six months. However, a 2012 national KAP study 13found that about 32% of mothers do not introduce complementary foods to children before they are one year of age. That study found that 36% of respondents provided children one to two years of age with complementary foods only once or twice a day. These findings may be due to insufficient food or poor feeding and care practices, and likely contribute both to acute malnutrition and be a major factor behind high rates of chronic malnutrition in this age group. While specific studies on intrauterine growth retardation in Rwanda were unavailable during preparation of the NFNP and NFNSP, the RDHS 2010 found levels of stunting to be 15% among infants two months of age. 14 This likely indicates many of these infants stunted at birth. Inadequate intrauterine growth results from poor health during pregnancy or inadequate nutrition. The latter may be caused by insufficient nutritious food in the household, poor eating habits or problems with intra household food distribution. Micronutrient Deficiencies Micronutrients, vitamins and minerals, play a major role in human health, growth and development. The hidden hunger of micronutrient deficiencies weakens immunity (iron), increases birth defects (folic acid) and causes fatigue and lower productivity (iron), increased morbidity and mortality (Vitamin A) and affects cognitive development (iron, iodine). Rwanda has solved major micronutrient problems with Vitamin A through periodic national distribution and administration of high dose Vitamin A supplements to vulnerable target group. Iodine deficiency has been addressed successfully through legislation requiring iodization of salt. In 2013 the Government approved standards for national mandatory fortification of industrially milled wheat and maize flour, cooking oil, sugar and salt. These staple foods produced in Rwanda and imported to Rwanda must contain specific amounts of key nutrients beginning in 2014. Iron deficiency While measures to improve micronutrient nutrition have substantially improved conditions regarding Vitamin A and Iodine, additional measures are needed to solve the serious problem of anaemia among women, especially pregnant women, and among children, especially those six months to two years of age. Because these are both period of rapid growth, pregnant and children from 6-24 months often cannot meet their iron needs through diet alone. Anaemia prevalence was 25% during pregnancy and 17% among women of reproductive age. More than 70% among children 6-12 months were found to have anaemia in 2010. 15 There are 13 Knowledge, Attitudes and Practices Assessment on Early Nurturing of Children The Ministry of Health and UNICEF ,Rwanda, Virginia Isingoma, Kigali: Ipsos Limited, (September 2013), 14 RDHS 2010. 15 RDHS 2010. 22 potential solutions for preventing and controlling iron deficiency anaemia for different groups in Rwanda. Staples fortification: According to the National Fortification Alliance, legislation passed in 2013 requires that staple foods for the general population be fortified with appropriate micronutrients beginning in 2014. While this will help with overall micronutrient nutrition staples fortification, including fortifying wheat and maize flour with iron, it will not fully address the iron deficiency problems of those groups who do not consume commercially milled flours of those who have high iron needs (pregnant women and young children). Biofortification: Rwanda has moved forward with research and trials of biofortified agricultural crops including biofortified beans. The bean varieties have been shown to be acceptable to farmers, have substantially higher yields and high levels of iron. Broad sales of these beans in Rwanda began in 2013 and other biofortified crops are also being promoted including varieties of cassava and sweet potatoes. Targeted fortification: Some commercially prepared foods are highly fortified with micronutrients in amounts that can meet the needs of young children and pregnant women. In-home fortification: In-home fortification of complementary foods for young children using small sachets of micronutrient powers (MNP) has potential to solve the extremely high anaemia prevalence in the 6-24 month age group. Successful operational research was complete in six districts in 2013. The use of MNP should expand as an intervention in community level programmes that had partner funding in 10 districts beginning in 2013. Iron + Folic Acid Supplementation: Iron and folic acid supplements are available to all pregnant women through antenatal care services. However, the 2010 RDHS find that only about 1% of women had used Fe/FA supplements for 90 days during their last pregnancy as is the recommendation from WHO. Broader and more effective FE/FA supplementation among pregnant women requires that supplies be available in health facilities, mothers attend early antenatal clinics, and health staff provide the supplements to every pregnant woman and those women take them daily as directed. Dietary diversity: a diverse diet includes vitamin and mineral rich foods. Such diet often require promotion and support for home activities such as raising and using iron rich animal products. Deworming: Deworming of children and pregnant women and children in health services and schools is well established and can help to reduce iron deficiency. In general, the successes and failures in this area point toward the need for more integrated approaches to be developed and for a comprehensive approach to micronutrient nutrition that includes an emphasis on prevention and control of Vitamin A deficiency and anaemia in key target groups. 23 Food, Nutrition and HIV/AIDS The synergy of malnutrition and infection is particularly strong in relation to the importance of prevention, treatment of HIV/AIDS. In Rwanda, 2011 estimates of the prevalence of PLHA among adults aged 15 to 49 ranges from 2.60% - 3.50%. There are from 180,000 to 250,000 PLHA in Rwanda. From 94,000 - 130,000 of these are women aged 15 and up and from [22,000 - 32,000 are children under the age of 14.16 Persons living with HIV/AIDS (PLHA) have special nutritional needs because they are more vulnerable to illness, malnutrition and death because of their compromised immune system. An estimated 8% of people enrolled in the ART programme are severely or moderately malnourished. In addition, those taking antiretroviral drugs have a need for additional protein compared to others. Complicating nutritional issues related to PLHA and those affected is the fact that many are among the more vulnerable economic groups based on simple poverty, the burdens of stigma affecting livelihoods or loss of family resources because of a relative’s death. The national HIV/AIDS programme provided protocols for nutritional support for severely malnourished on ART using therapeutic milk and for fortified supplementary foods (CSB or SO SOMA) for moderately malnourished using antiretroviral therapy. Supplemental food is called for children suffering from HIV/AIDS along with close monitoring because they do not respond well if they become acutely malnourished. A supplemental food supply of staples and key commodities is recommended for families of PLHA. Prevention of Mother to Child Transmission (PMTCT) has improved substantially because of effective promotion of breastfeeding and the fact that beginning in mid-2009, 98% of pregnant women who tested positive received antiretroviral therapy for PMTCT. PMTCT decreased from 2.6% in the previous 12 months to 1.9% for the year. These achievements need to be sustained. Hygiene, Sanitation and Safe Water Problems of water, hygiene, and sanitation affect the synergy between malnutrition and infection. High priority for hygiene is justified because improved personal and domestic hygiene practices can reduce diarrhoea by over 65% (e.g. hand-washing with soap at critical times is estimated to reduce diarrhoea by 47%) compared to safe water that links to a 15% reduction). Improving nutrition in Rwanda will require continued emphasis on promoting total access to hygienic latrines and hand washing and careful preparation of foods for the family and especially young children. Greater emphasis is needed on careful handling of young child faeces. 16 UNAIDS report 2012 (based on 2011 Rwanda national data). 24 A Community-Based Environmental Health Promotion Programme (CBEHPP) led by MININFRA and the Environmental Health section of the MINISANTE was launched in 2009. This initiative has been effective in districts that had additional support from Development Partners. It needs to be strengthened and expanded though use of lessons learned from these districts where substantial improvements were achieved. Over nutrition and Chronic Disease Rwanda’s continuing rapid economic growth and urbanization, problems of over-nutrition, poor food choices and poor eating habits grown in importance. Overweight in Rwanda is both a rural and urban issue, but obesity is found mainly in urban areas and towns. Among women nationwide, 16% were found to be overweight or obese in 2010.17 The rates in urban areas are 25% compared to 15% in rural areas. In the City of Kigali 30% of women were found to be overweight or obese. Among children less five years 7% of children were found to be overweight or obese in 2010.18 This set of problems has already caused increased numbers of cases of nutrition-related chronic diseases. The country needs to monitor these conditions and diseases closely and more fully develop appropriate prevention and treatment strategies. National surveys in 2010 and 2012 studies found about 17% of women to be overweight compared to 7% wasted.19 Household Food Security Disease prevention is synergistic with sufficient dietary intake in terms of amounts and types of food and eating/feeding practices. Adequate dietary intake among young children 6-24 months of age most often requires continued breastfeeding, nutrient dense food and micronutrients, as well as health care for all pregnant and lactating women and children from 6-23 months. Adequate nutrition intake may require the availability of nutritious foods in the home, knowledgeable selection of what to eat, skilled preparation practices. These all affect the nutrients received. Problems with any of these conditions may contribute to poor household food security. The scope of household food security as viewed by Rwanda’s National Food and Nutrition Policy is broad and corresponds with the international model for the 2012 Comprehensive Food Security Vulnerability Analysis and Nutrition Survey as shown in Figure 3: 17 RDHS 2010 18 RDHS 2010. 19 RDHS 2010, CFSVA/NS 2012. 25 The CFSVA/NS 2012 found further evidence of increased food production but also found that nutritious food remained a problem at various times of the year for 51% of Rwandan families and 21% at the time of the survey20 This suggests that providing adequate healthy food for young children is a challenge for many families. When children from families with problems of food access also become ill, the combined could explain a sizable portion of the high prevalence in chronic malnutrition among children under five years. The rates of stunting, while high throughout the country, vary by region. The highest rates are in the northwest and west and the lowest in the urban area of Kigali and in the eastern provinces. These factors that correlate with the highest levels of child stunting in Rwanda include inappropriate feeding practices of children between 12 and 23 months, mothers’ education, poverty levels and easy access to health facilities.21 As noted, complementary feeding is a major problem in many families as indicated by the high rates of stunting during the period between exclusive breastfeeding and a child’s adoption of a diet closer to older children. While many complementary feeding problems may be the result of poor practice, many are likely to be related to insufficient access to the foods needed to prepare the foods needed to support healthy growth, cognitive development and overall health. This alone suggests that providing adequate healthy food for young children may be a challenge for many families. Problems of inappropriate complementary feeding practices combined with high incidence of infectious disease in children could explain a sizable portion of the high prevalence in chronic malnutrition among children under two years of age, 20 Much of the CFSVA and Nutrition Survey 2012 data collection took place at a critical moment in the lean season for many households. (CFSVA/NS 2012) . 21 CFSVA/NS 2012, RDHS 2010. Figure 3: Conceptual Framework for Assessing Food Security 26 The problems of household food security and their malnutrition were well recognised by the MINAGRI in its Nutrition Action Plan (NAP). Those MIINAGRI strategies incorporated into the NFNP and NFNSP are expected to positively impact on household food security among vulnerable families in targeted districts. Social Protection and Malnutrition While there have been achievements in services and practices related to preventing infection, improving household food security and nutrition related services from the health sector many families in Rwanda do not have resources to obtain the food needed nor the knowledge skills required to bring healthy meals to their families. Although food and nutrition for the extremely vulnerable and poor requires better linkage of the health and agriculture sectors, stronger links to social protection services are also required. These may be in the form of cash transfers, food supplements, food for work and VUP project services. The NFNP takes into account the achievements and plans for continued rapid expansion of the social protection services including social assistance from government revenue assistance, social insurance and employer funded programmes such as maternity benefits. Without such services and programmes, the poorest and most vulnerable individuals and families groups cannot move up from a position often on the brink of malnutrition. When the operational nature of Rwanda’s social protection services is examined, cash transfers target groups that are in need of the resources to purchase or grow foods needed for minimal nutrition. Free mutuelle (community health insurance) allows the poorest access to primary health care services including all of those noted as being linked to the prevention of chronic malnutrition in children. However, cash for food or basic food supplements and health care services will not bring the poorest groups out of their situation. Agriculture is viewed as a major pathway away from social assistance in Rwanda. Agriculture related activities are the broadest range of services and inputs that have the potential to “graduate” participants to self-sufficiency in the context of social protection. Many VUP projects involve improving and protecting agricultural land and its productivity. From MINALOC, many of the supplies, cash transfers, microfinance and other services aimed toward vulnerable groups are linked to new or improved small scale food production, or to the direct purchase of foods by beneficiary families and individuals. The supplies provided to vulnerable groups through social protection services such as cows, seeds, small animals and fertilizer flow from the MINAGRI. The use of these inputs can be linked directly to more nutritious diets. They also have the potential for increasing the family access to health food on a sustained basis. Such inputs reinforce the importance of assuring that agricultural strategies and interventions that aim toward improving nutrition are well targeted toward the vulnerable as beneficiaries. The NFNSP 2013-2018 closely follows the recommended priorities of the Social Protection Policy (NSPP) (2011). Targeting with the context of this strategic plan will follow the expansion of social protection services and the continual improvement of targeting. In selecting participating individuals and groups, the NFNSP will follow the NSPP principle of 27 beneficiaries having the right to appeal if they are not selected. Services provided under the NFNSP will be viewed as assisting families in the most vulnerable groups to “graduate” out of social protection. In addition, the NFNP recommends that district and community level nutrition and household food security interventions recognise the benefits of actively linking with social protection programmes and collaborating with MINALOC officers who reach deeply into communities and offer powerful channels for promoting key services of agriculture and health that affect food security and nutrition to vulnerable families. Nutrition, Household Food Security and the Family Analysis of the situation on nutrition and household food security in Rwanda is not without consideration of the services and activities that focus specifically on women and families. The Ministry of Gender and Family Promotion (MIGEPROF) significantly enhanced its focus on nutrition and food security at family level, since 2010 when the NmSEM was adopted by the Social Cluster Ministries and MIGEPROF joined in developing, supporting and monitoring the JAPEM. Laws addressing basic Issues that affect malnutrition An unquestionable achievement of Rwanda in addressing the basic causes of malnutrition has been the successful advocacy and technical work by MIGEPROF and its Development Partners on key legal issues related to gender and the family. Rwandan laws now guarantee women the right to inherit land and other property, and have codified as criminal gender based violence. Women are also legally guaranteed equal access to food production in the family. Gender sensitivity has become a requirement throughout Government and is actively promoted in the private sector and society. MIGEPROF national level nutrition promotion Direct and underlying causes of malnutrition became the central theme of MIGEPROF’s nationally monthly broadcast television and radio programmes with the MINISANTE collaborating on content. National month long MIGEPROF “Family Campaigns” use support mobilized mainly from NGOs to poor assist families with children suffering from acute malnutrition by providing cows, small livestock, seeds, and in some cases high quality foods. Since 2011, a MIGEPROF cell level programme promotes Agakono k’umwana, aimed at revitalizing a well-known traditional household practice of having a special ”pot” of nutritious foods for young children. MIGEPROF also organizes “Annual women’s campaign” mobilizing for health and nutrition at family level and advocating the wellbeing of the family as a whole and women in particular. Support for community level nutrition improvement Similar to the MINISANTE, the potential impact of active MIGEPROF involvement in activities to improve the nutrition and household food security of poor families is substantial 28 because its organizational reach to community level through National Women’s Council Village Committees (NWCVC) led by an elected local chairwoman. These committees and their chairwomen are potentially effective allies in nutrition promotion. Their monthly gatherings already mostly centre on collective cooking emphasizing health meals for lactating women and children at the age of complementary feeding (6-24 months). Additional potential is found in the national “Family Commitment” programme through which MIGEPROF calls for every family to maintain a “family performance notebook” with objectives and progress on assuring or improving family nutrition, crops, education, economic growth, and early childhood development ECD). While food and nutrition are central focus of these activities and commitment is high, effective implementation has been constrained by technical and organizational capacity limitations, particularly at cell and village levels. The result has been limited integration of these activities and weak links to nutrition and household food security related programmes of the MINAGRI, and the MINISANTE at cell and community levels. Food and Nutrition in Schools School attendance has been steadily increasing in Rwanda offering both greater opportunities and also some additional risks regarding food and nutrition. The Ministry of Education (MINEDUC) recognizes that many students from preschool through secondary, in both urban and rural areas, come to school and go home hungry with serious negative impact on what they learn. Teaching and learning about Food and Nutrition The Education Sector Strategic Plan 2010-2015 (ESSP) calls for All school improvement plans and school management and evaluation programmes to prioritise the promotion of nutrition along with health hygiene and sanitation services in schools. It also recognises that food and nutrition issues need to become prominent areas of teaching and learning in schools at all levels through curriculum based, and extra curricula activities. School gardens are proposed as teaching learning activities that focus on food and nutrition and the inclusion of more strategically identified food and nutrition topics at different levels of the curriculum. School feeding Overt hunger in schools is not uncommon, micronutrient deficiencies (anaemia) is prevalent among school children as are worm infestations. Programmes to address feeding of students were limited. Within that policy the One Cup of Milk per Child programme that then covered about 75,000 children in 100 schools was to be expanded. The programme of subsidizing secondary school tuition by providing meals was slated to continue and expand. A school feeding programme for highly vulnerable districts formerly supplied with food from WFP was moving toward closedown with only about 80 schools covered. In 2012-13, a “white paper” by MINEDUC/WFP outlined, justified and estimated costs for the national “Home Grown School Feeding Programme” That is intended to bring a meal to 29 every school child. The implementation of that Home Grown School Feeding is called for in the School Health Policy. Implementation is expected to be major effort that will require resource mobilization at all levels from international and national to community. The completion of the substantial organisational arrangements needed at different levels and in different environments and types of settings (urban, town, rural) will also be challenging. When implemented on a large scale, the Programme will have benefits to the educational system, to pupils, and to small scale farmers in the communities. Health and nutrition – student assessment in schools Another food and nutrition related activities recommended in the 2013 School Health Policy is incorporation of various nutrition indicators into new school health and nutrition assessments of children. Also recommended are limited levels of school feeding, provision of milk, school gardening and farms that serve as learning opportunities for students and inclusion of some nutrition topics at different levels of the curriculum. Deworming activities in schools have been carried out nationally in collaboration with MINISANTE. The Education Sector Strategic Plan (ESSP) places emphasis on food and nutrition through the curriculum and “Life Orientation” learning areas, supplemented with co curricular/school-based activities and development of gardening programmes. Organizational linkage Active linkage to the MINISANTE will needed for collaboration on health and nutrition related student assessments and for content advice on food and nutrition curriculum content. Linkage will be needed with the MINAGRI to support expanding the programme providing milk for students, and for activities involving small livestock and gardening. MINAGRI involvement will also be needed to assist in working out sources of appropriate local foods for schools under the Home Grown School Feeding Programme. Challenges are expected in developing community ownership and support of school health and nutrition, improving hygiene and physical activities including school sports, and contributing to the home grown school feeding programme. Another anticipated challenge area that will require innovative solutions is development of gardening and related activities primarily as valuable teaching learning activities in both rural and urban areas. Overcoming this challenge will require operational research and promotion with school staff. Recent innovations in urban gardening and schools should be used to assist. Food and nutrition in emergencies Food and Nutrition for Refugees More than 74,000- refugees were living in Rwanda in 2013 with more than 32,000 having arrived from the Democratic Republic of the Congo in 2012. Refugee camps receive food supplies and non-food assistance. The populations of these camps face several constraints affecting health and nutrition that may include overcrowding, hygiene and sanitation 30 problems, issues with food distribution, firewood supplies and relations with the populations of surrounding areas. The Ministry of Disaster Management and Refugee Affairs (MADMAN) has UNHCR as its main UN counterparts. Technical issues related to food and nutrition for refugees were generally dealt with by development partners assisting with supplies, and international guidelines as well as in camp assistance. An area needing significant improvement involves better information sharing from the level of the refugee camp or point of emergency to key decision makers in the Social Cluster Ministries and development partners. The development in 2013 of strategic plans by MADMAN concurrent with work on the NFNP provided an opportunity for nutrition to be introduced more systematically into preparedness planning and response to both disasters and refugee affairs and initial policy guidance is introduced as one of the strategic direction. These plans take into account the country’s Strategic Grain Reserves which have been used in emergencies resulting from floods and droughts Additional Information sources informing the development of the NFNSP In addition to information from formal sources analysis of the situation and determination of not only what is needed but what is possible requires attention to lessons learned from with DPEM planning and monitoring and implementations from sector and community level work on innovations and innovation packages aimed to achieve improved nutrition and household food security. Many of the innovations introduced and carried out on a small scale in various districts and many communities had not yet been implemented on a wide scale nor had potentially useful lessons learned been proudly disseminated. Information of this type was accessible in the form of presentations and abstracts prepared for the Second National Nutrition in 2011. The materials from that meeting also provided additional information on the international research on innovations relevant to chronic malnutrition and household food security. Achievements under the 2007 National Nutrition Policy and challenges remaining in 2013 Overall analysis of the situation provided a summary of achievements that took place under the era of the 2007 National Nutrition Policy and those that remained major food and nutrition challenges remaining in 2013. (See Table 1) These remaining challenges are addressed in this updated and revised National Food and Nutrition Policy 2013.. National Food and Nutrition Strategy Framework and Implementation Plan 31 Table 1 : Key Achievements and Challenges of NNP (2007) Major Achievements National Nutrition Policy (2007) Remaining Challenges to be Addressed by the National and Nutrition Policy (2013) National priority of nutrition and household food security EDPRS 2, HSSS III, MINAGRI NAP include substantial emphasis on nutrition and the HSSP III includes specific nutrition objectives including reductions in acute and chronic malnutrition in children. Rwanda joined the Scale UP Nutrition Movement. MIDIMAR and representatives from United Nations Agencies) confirming cooperation in Disaster and Refugee Management programmes. A specific results area on nutrition added in Development Group 3 (One UN) Sustaining the achievements through continued evidence based advocacy Assuring a flow of policy related information on successful strategy and programme innovations to all levels including the highest level of Government. Practical but challenging policy and strategy objectives. Assuring opportunities for partner and donor assistance are not missed and are adequately followed up with required and advocacy focused reporting. Funding for development of district plans to eliminate malnutrition needs stronger guarantees from Government and development partners. Active identification and management of acute malnutrition Substantial reductions in acute malnutrition among children through adoption of National Protocol for Management of Malnutrition (2009). Capacity building of CHWs on screening and on National Protocol. Presidential Initiative to Eliminate Malnutrition along with on-going follow-up. Building sustainability for clinic and community level identification and use of the protocol. Improving the overall system for procurement, supply and efficient logistics around commodities needed for severe and moderate cases. Chronic malnutrition in children under two year 32 Shift in priorities to prevention of chronic malnutrition as well as active identification of acute malnutrition (200(). Substantial but insufficient reduction in chronic malnutrition among children under five and particularly in children under two year old children. Initial implementation of decentralised cross sector approaches through NmSEM JAPEM and DPEM (2010 2013. Launch of the National 1st 1000 Days Campaign to prevent stunting in children under two years of age (2013). Developing effective, decentralised intervention programmes to further reduce stunting and sustain objectives HSSP objectives on chronic malnutrition and those in EDPRS 2. Sustaining a national, multi-sector campaign to promote the concept of 1st 1000 Days, the importance of related services and key practices nationwide. Assurance of development partners support for DPEM implementation focusing on stunting. Developing an effective linkage between national 1st 1000 Days Campaign and refocused decentralised and community-based nutrition programmes in all districts. Strengthening DPEM to fully link with 1st 1000 Days to Prevent Stunting National Campaign. Obtaining Development Partner support for DPEM planning and monitoring. Assuring full integration of DPEM into District Development Plans and District Budgets Sector specific household food security and nutrition-sensitive policies, strategies and programmes 33 Household food security and nutrition focused plans and strategies developed by key Social Cluster Ministries. Nutrition Action Plan by MINAGRI. School Health Policy by MINEDUC. Social and Behaviour Change Communication Sub-Strategy for Maternal, Newborn and Child Health by Ministry of Health. Community-Based Environmental Health Promotion Programme (CBEHPP) by MINISANTE and MININFRA. Development of Early Childhood Development Policy (MINEDUC). Implementation of CFSVA&NS rounds Operationalisation of sector-specific nutrition and household food security related strategies and policy. Enhancing collaboration and coordination within and across sectors and partners to assist and implement activities to reduce chronic malnutrition in all districts. Assuring sector specific activities link with all major policy objectives and are not viewed as “sector contributions to the NFNP. Linking nutrition activities in also contribute to 1st 1000 Days Community Based Programme Objectives. Assuring 1st 1000 Days concept enhances support for related services and interventions that contribute directly or indirectly to improved nutrition, household food security and prevention of infections Micronutrient deficiencies Major improvements in Vitamin A supplementation coverage. Iodine nutrition improved universal access in iodine nutrition through iodize salty MINISANTE Substantial but insufficient improvement on anaemia in, pregnant women and children, particularly those <2. Building and promoting a, multi-intervention package to prevent Vitamin A deficiency. Assuring iodine deficiency diseases and iodized salt are monitored and any problems addressed. Developing an effective, affordable, practical national strategy to prevent and control anaemia particularly targeting children under five, under two and pregnant women. Developing appropriate operational research on zinc deficiency and prevention strategies. Nutrition in emergencies 34 New MIDIMAR set up and operational linkage was established with key Ministries and Development Partners. Major influx of refugees from the DRC well managed and adequate food provided including special foods for most vulnerable groups including pregnant and lactating women and children less than five years. Establishing a rapid communication system in early warning services in emergencies. Assuring well developed strategies and emergency preparedness plans that are compliant with international guidelines in the areas of nutrition. Capacity building in food and nutrition Multiple in-service trainings of CHW and support materials In MIYCN BA Program in Nutrition Initiated (KHI) Multiple orientation and training opportunities for clinicians and nutrition officers On-going training and supportive supervision of CHWs and health staff at all levels in areas related to improving house hold food security and nutrition. Addressing the immediate need to develop and implement an effective strategy to strengthen supportive supervision of CHWs in nutrition related activities Designing and developing a funding strategy for a national short, medium, and long-term nutrition capacity building plan and strategy and priority activities of the plans. Developing, producing , effectively disseminating, and orienting users on high priority materials to support 1st 1000 Days Community Based Programmes Private sector food production and processing linkage to nutrition related non communicable disease) Monitoring, evaluation, operational research and information sharing 35 RapidSMS introduction extended to nutrition indicators. Introduction of Food Security and Nutrition Monitoring System. Introduction of nutrition variables into RapidSMS. Introduction of District level sampling and analysis- RDHS Indicator improvements in Household food security and Nutrition-CFSVA&NS Successful large scale operational research and effectiveness study on Micronutrient Powders for in home fortification. 1st and Second National Nutrition Summits organised. Effective sharing of relevant strategic and programme information including areas of important gaps through the first and second National Nutrition Summits. Improving nutrition surveillance and feedback channels into operational groups facilitating and supervising district and lower level programmes and plans. Continued emphasis on using an evidence base for policy advocacy, strategy priorities, objective setting and intervention selection. Expanding and strengthening the RapidSMS system to national scale in all districts and to better facilitate feedback and analysis at all levels. Developing improved systems for active, on going information sharing on programmes across districts and between national and international levels and districts to support 1st 1000 Days and other household food security and nutrition programmes. Developing an effective forum for useful information exchange to support DPEM and 1st 1000 Days national campaigns and community based actions nationwide. Improving information sharing on nutrition and food security problems of refugees and those in emergency situations Nutrition and Household Food Security Governance and Coordination 36 Leadership of DPEM and JAPEM given to MINALOC expanding policy ownership. Social Cluster decision to rename policy to National Food and Nutrition Policy. Ownership of NFNP expanded to MINAGRI, MINISANTE and MINALOC with active participation of other sectors. Active participation of nutrition focal points and technical personnel from all Ministries in the Social Cluster Nutrition Technical Working Group meetings. Active participation of Provinces and Districts multi-sector teams in planning and in development of District Plans to Eliminate Malnutrition Active participation in development of the NFNP. Assuring that sector budgets for nutrition continue to include and increase contributions for multi-sector activities and that these are effectively coordinated to assure high levels of synergy and no redundancy in the multi-sector interventions and program activities. Assuring full integration of District Plans to Eliminate Malnutrition into District Development Plans and District Budget” Completing and implementing Governance model design for national and decentralised actions to improve nutrition and household food security. Costing of new interventions and programmes called for under the NFNP and NFNSP (2013 2018). Further improvements to multi-sector monitoring and evaluation systems to support nutrition and household food security programmes and strategies. Further strengthening linkages with partners and donors. Improving decentralised activities and participation in planning, implementation coordination and monitoring Improving the communication and sharing of data from the district on malnourished families and children to allow many stakeholders to better plan and coordinate and mobilise resources for related work. Conceptual Framework for the National Food and Nutrition Policy The National Food and Nutrition Policy uses a conceptual framework adapted from HSSP III. This framework includes “Leadership and Governance” showing the ownership of the policy broadened to three Ministries with other Ministries and development partners including NGOs, actively participating. Governance includes multi-sector ownership, sector-linked 37 budgets and financial management nutrition related interventions that are the responsibility of a specific sector and contributions to jointly operated strategies and programmes. Decentralization, participation, equity and gender sensitive are essential components of good government. These each inform the NFNP strategic directions, and recommendations on organizational and coordination mechanisms. Leadership, and good governance along with the programmes and program support feed into a set of food and nutrition services and food and nutrition support promotion delivery systems. The delivery systems in this multi-sector field include joint and collaborative activities and require added support and improvement potential through monitoring and information sharing within and across the delivery systems levels. The delivery systems that generate outputs work both independently and in collaboration on different strategic directions. The outputs generate outcomes that improve nutrition for the population. (See Figure 4) Figure 4: Conceptual Framework of the National Food and Nutrition Policy 38 Vision, Mission and Objectives of the National Food and Nutrition Strategic Plan 2013 2018 NFNP Vision The vision of the NFNP is to ensure services and practices that bring optimal household food security and nutrition for all Rwandese. This policy is based on the values of solidarity, ethics, and equity, as well as cultural diversity and the importance of gender, for the harmonious development of Rwanda as a nation. NFNP Mission The mission of the NFNP is to provide a legal framework and favourable environment for the effective promotion and implementation of food and nutrition strategies and interventions that guarantee the nutritional well-being of the entire population giving special attention to pregnant and lactating women and children under two years of age for the sustainable development of Rwanda. NFNP Objectives and Outcomes General objective The general objective of the National Food and Nutrition Policy is to improve the household food security and nutritional status of the Rwandan people, to substantially reduce chronic malnutrition in children under two years of age and to actively identify and manage all cases of acute malnutrition. Specific of objectives of the NFNSP In order to improve the food and nutritional status of the population, the policy seeks to achieve the following specific objectives derived from HSSP III: To reduce the prevalence of in underweight among children under five years of age from 11% (2010) to 6% (2018). To reduce the prevalence wasting from 3% (2010) to 2% (2018). To reduce the prevalence of chronic malnutrition in children under two years of age from: 44% t (2010) to 24.5% (2018). Strategic objectives and key expected outcomes Sustain the position of Food and Nutrition as Central Priorities of the Government across Sectors at all levels and among Development Partners. (Strategic Direction 1) Wide dissemination of the National Food and Nutrition Policy has occurred. Food and nutrition remains a foundational issue of EDPRS 2. 39 Prevent stunting in children under two years of age. . (Strategic Direction 2) 1st 1000 Days Programme activities are implemented nationally District Plans to Eliminate Malnutrition are integrated, effectively strengthened and implemented The 1000 Days Community based program me is strengthened Strengthen, expand and promote services and practices that result in household food security year round for the full population. . (Strategic Direction 3) Household food security has improved as measured by fewer families having problems in accessing the foods needed for a healthy diet throughout the year. Household food security strategies of the MINAGRI are closely linked to vulnerable households. Households nationwide have greater knowledge and skills related to producing or obtaining, preserving, processing, preparing and feeding high quality foods and meals needed for healthy complementary feeding and a healthy diet for the pregnant women and other family members. Prevent and manage all forms of malnutrition. (. (Strategic Direction 4) Low prevalence of severe acute malnutrition is sustained and further lowered through active identification and management and preventive services and widespread use if innovative technologies (RapidSMS). MIYCN with has been strengthened through capacity building at all levels with added emphasis on optimal complementary food and feeding practices and the nutrition of pregnant and lactating women resulting in better nutrition for these groups. Nutrition of the sick child is effectively promoted through IMCI. Sustain and strengthen effective policies and programmes to prevent iodine deficiency and vitamin A deficiency. All salt in the country is iodized. The prevalence of anaemia in children and women is lower in accordance with the objectives set in the HSSP III. PLHA and their families are receiving the nutritional support they require and food and nutritional support is more widely practiced in PMTCT. Effective promotion of appropriate infant and young child feeding has contributed to achieving nation targets for PMTCT and PLHA including children and affected families; as well persons with tuberculosis are receiving needed nutritional support. 40 Diarrhoeal disease prevalence among young children has continued to decrease. Prevention of overweight and obesity has become a priority topic of health promotion and the MINISANTE policy on non-communicable diseases is being actively implemented Information generation and its use regarding obesity and nutrition related non communicable diseases have improved. Strengthen nutrition education in schools and higher learning institutions through curricular and extracurricular activities. (Strategic Direction 5) Food and nutrition education has been substantially expanded throughout school curriculum and extracurricular activities. 1st 1000 Days” has been introduced and become part of curricular an extracurricular activities. Expand and improve school feeding by giving special attention to home grown school feeding programs. “Home Grown School Feeding Programme” has been successfully introduced One Cup of Milk per Child, programme (with MINAGRI) has expanded and integrated into the Home Grown School Feeding Programme.” Increase food and nutrition sensitivity in emergency preparedness and response. (Strategic Direction 6) An early warning system for disasters and preparations for the adequate nutritional care of affected persons are in place. Preparations for prompt and adequate food and nutrition response to a large number of refugees is in place More vulnerable persons among existing refugees are provided with adequate food and nutritional care and support. Improve governance systems and accountability (planning, budget allocation, implementation and monitoring and evaluation) for nutrition and food security. . (Strategic Direction 7) Assure provision of the supportive programmes and services needed for policy implementation of NFNP policy. Needed supplies and commodes relevant to strategy implementation are on hand and well disseminated on a regular basis. DPEM have regular technical support from sector specialists and development partners. 41 Monitoring &Evaluation is adequate, Data is more accessible and transparent, Operational Researches are conducted and Information Sharing systems are in place and functional. Adequate communication support is provided. Human and national capacity building in food and nutrition are progressing. Strategic Plan priorities for improving nutrition and household food security The seven strategic directions covered in the NFNSP 2013-2018 correspond to those in the NFNP and outline five years of work to move NFNP implementation forward. The strategic directions call for practical approaches known to be effective. In most cases they are intended to be managed using existing organizational structures and resources. Taken as whole, the outcomes and activities for each strategic direction are the starting points for making progress during the next five years on the country’s most serious nutrition and household food security problems. These approaches take into consideration the current commitments of the Social Cluster Ministries to addressing nutrition and household food security problems. They also consider current levels of human and financial resources and those that can be reasonably expected to become available through Government budgets and from Development Partners. Principles behind the Policy’s Strategic Directions Underlying the NFNP and each of the strategic directions and the interventions are principles similar to those used to underlie the 1997 National Nutrition Policy. These are foundation for effective policy implementation and good governance in Rwanda. Decentralisation, community participation, multi-sector collaboration, gender sensitive and equity The strategic directions in the NFNP and NFNSP are highly consistent with Rwanda’s commitment to decentralisation. Where possible, they place emphasis on district level planning and intervention implementation and monitoring. They rely on and include community participation and ownership of key activities. In all cases, the strategies of the NFNP are gender sensitive and, where possible, push forward equitable access to appropriate food and nutrition services including social protection. Empowerment Principle of empowerment is achieved through community-based, highly participative activities aiming at improving nutrition and household food security in an efficient and, potentially, highly effective. A major strategic direction of the NFNP links the national campaign to prevent child stunting with District Plans to Eliminate Malnutrition and also with organised, regular community based activities focused on the 1st 1000 Days CBF&NP to Prevent Stunting. The NFNSP Strategic Directions and intervention packages emphasise making better use of existing basic services, simple and affordable techniques, and useful information that can be 42 effectively used by families. Priority is given to more frequent joint participation by frontline specialists and workers from other sectors besides health. Empowerment of communities also comes through participation in the management process (prioritisation, planning, implementation and monitoring). Government workers and development partners are expected to provide technical support and capacity building. Synergy and integration among activities The NFNP emphasis on integrating activities recognises the close linkage of poverty and food, nutrition, and health. This requires appropriate integration of household food security strategies into strategies and programmes of each Ministry in the Social Cluster and into the work of NGOs and other Development Partners. The NFNSP includes strategic directions that are fully multisector requiring several Social Cluster Ministries to work together. These include Strategic Directions 1, 2, 6 and 7. Other strategic directions are more focused on a specific sectors including household food security (Strategic Direction 3), nutrition interventions closely linked with health (Strategic Direction 4), another focused on school feeding and food and nutrition learning and another focused on nutrition in emergencies. Despite their sector focus, none of the strategic directions can implement the intervention packages they include without involvement from more than one Ministry. The multisector participation requirements for effective implementation of the NFNSP will bring synergy to intervention packaged that address the multiple causes of child stunting through integrated solutions. This requires cross-sector collaboration, joint activities and active partnerships. Collaboration and active partnerships Because many of the strategies needed to fight against malnutrition in Rwanda follow multisector approach, collaboration and active partnerships are needed for their success. The NFNP is co-owned by MINAGRI, MINISANTE and MINALOC with and major responsibilities of Strategic Directions by the MINISANTE, MINAGRI, and MIGEPROF, MINEDUC and MIDIMAR and active collaboration from the other Social Cluster Ministries and Development Partners. An effective nationwide response that addresses the priorities of the EDPRS 2 requires sectors to both allocate a share of their resources and work together where needed. While collaboration is required for success, the NFNP also takes into account each Ministry’s mandate, responsibilities and human resources. Effective coordination Coordination within and among the NFNP strategies is critical for successful implementation. The priority for effective coordination was reflected in the strategic decision to organise a Food and Nutrition Steering Committee (SCF&NSC) within the Social Cluster Ministries under the Prime Minister’s Office. Similar Food and Nutrition Steering Committees (DF&NSC) are planned at District level to assure District Governments have the 43 support needed to bring all sectors in together in DPEM strengthening, implementation, monitoring and reporting. Strategic Directions of the NFNP Building on these principles, the NFNP includes seven Strategic Directions that include packages of interventions that relate closely to the major problem areas outlined in the situation analysis. They also considered international priorities and recent research relevant to Rwanda’s major issues of nutrition and household food security. Six operationally focused strategies are complemented by a seventh strategy encompassing required support services. The seven NFNP strategic directions, their major interventions and illustrative expected outputs are briefly described in the following section. They are outlined in greater detail in Rwanda’s National Food and Nutrition Strategic Plan for 2013-2018. Strategic Direction 1: Food and nutrition advocacy to sustain commitment and generate resources for implementation Specific policy objective and expected outputs The specific objective for this strategic direction is to sustain the position of Food and Nutrition as Central Priorities of the Government across Sectors at all levels and among Development Partners. This includes assuring wide dissemination of the National Food and Nutrition Policy has occurred and food and nutrition remains a foundational issue of EDPRS 2. The monitoring and evaluation framework for Strategic Direction 1 is found in Annex 1 Rationale The movement of food and nutrition problems and issues to a central and high position in the country’s development objectives was achieved by 2010. This was demonstrated by the EDPRS 2 inclusion of food and nutrition as a foundational issue and incorporation in HSSP III of nutrition-specific and nutrition-sensitive objectives and indicators to be achieved by 2018. The magnitude, persistence and causal complexity of remaining and emerging food and nutrition challenges requires that central positioning of food and nutrition on the national agenda be sustained. To assure the NFNSP objectives and approaches compete well on the overall national development stage, Advocacy and resource mobilization are viewed as essential requirements for effectively implementation of the NFNSP 2013-2018 and set of interventions focused on these critical areas are the focus of the first strategic r]direction of the NFNSP. Support services, monitoring and evaluation, immediate and longer terms capacity building and operational research and information sharing are also recognized as keys to generating effective intervention synergy and for the seventh strategic direction of the NFNP and NFNSP. 44 Strategic Direction 1 in the NFNP framework will use strategic advocacy, to sustain and further build commitment among all levels of Government, not only to the importance of food and nutrition for health and national development, but to supporting the multisector, multi-level approaches needed for policy implementation. The strategic direction also aims toward broader commitment to cross sector participation at district level and integration of food and nutrition interventions into District Development Plans and budgets. Full dissemination of the NFNP in forms ranging from the full document to summaries and electronic versions accompanied by channels for feedback, will be part of powerful advocacy strategy. This strategic direction also addresses the national priority of preventing stunting in children by reaching every family about the central importance of the 1st 1000 Days. It also targets Government and NGO staff members responsible for providing more of the many services needed to prevent stunting and those involved in promoting the practices that help prevent chronic malnutrition in children under two. This strategic direction on advocacy and resource mobilisation requires multiple data types and sources. These include data-based evidence drawn from national sources such as the RDHS and CFSVA/NS and international sources. Human interest information drawn from stories around NFNP implementation successes and constraints will also be used. Data from districts succeeding with and rapidly scaling up their DPEM are viewed as a source useful to districts where there are problems. Such information will be a source for efforts to secure policy implementation resources from Government mainly through sector and district budgets and from Development Partners. Resource mobilisation efforts targeting Development Partners will link the NFNP to international guidelines and up-to-date research and movements such as “Scale Up Nutrition” as well as the information on progress and constraints regarding Rwanda’s, multi intervention, multi-strategy decentralized approach to improving nutrition and household food security. The NFNP linkage to international guidelines and up-to-date research and movements such as “Scale Up Nutrition” will be complemented by the information on the integrated, multi intervention approach, stories of progress and constraints and illustrations of strong principles of good governance. These sources will be used in resource mobilization efforts targeting Development Partners. Some of the interventions under this strategy that will reinforce and strengthen political commitment, and generate resources include the following: Strategic policy dissemination to national, provincial and district levels, development partners and others in multiple print and electronic formats. Resource mobilization at national levels with sectors through linkage of policy objectives to sector policies and plan. 45 Resource mobilization with development partners through data-based advocacy demonstrating effective NFNP implementation and pointing to areas where support is needed in the policy framework at national, district and community levels. Nutrition and household food security surveillance systems are also needed for cross checking food and nutrition surveys. Strategic plans from the Social Cluster Ministries each contain monitoring systems that can be *brought into use to create a strong multi-sector information base for decision making. Implementation Priorities of Strategic Direction 1 Advocacy and resource mobilization for NFNP implementation will be addressed through the NFNSP 2013-2018 which provides a multiyear overview strategy to define, schedule and guide these activities. Broad, dissemination of the NFNP and the NFNSP (2013-2018) are immediate activities based on Social Cluster and Cabinet approval. Active participation in NFNP advocacy and resource mobilization will be expected from a variety of concerned stakeholders. Funding for key activities is expected to become available mainly from Development Partners. Management of advocacy and resource mobilization will be led by the Social Cluster Food and Nutrition Steering Committee (SCF&NSC) with technical support from the NF&NTWG that includes Development Partners. Outputs and key activities Key activities CR 201 4 201 5 201 6 201 7 201 8 Responsible Partners Budget (RwF x’000) Output: Central position of food and nutrition among national and district development priorities is sustained. Widely disseminate the National Food and Nutrition Policy at national and district levels (full document, policy brief, presentations at National Nutrition Summit). X MOH MINALOC MOA SCM DP 20,430 Target each Social Cluster Ministry for annual briefings and updates on NFNP implementation progress, constraints, adjustments and resource requirements. X X X X X SCF&NSC SCM DP 2,084 46 Key activities CR 201 4 201 5 201 6 201 7 201 8 Responsible Partners Budget (RwF x’000) Assure Food and Nutrition remains a foundational issue of EDPRS 2. SD222 Act 221&222 X X X X X SCF&NSC SCM DP Assure DPEM are integrated into District Development Plans X X SCF&NSC MIGEPROF MININFRA MINEDUC DP Develop qualitative and quantitative information collection strategy to feed into NFNP advocacy materials and briefings. X X SCF&NSC SCM DP 24,923 Resource available at all levels for implementation of the National Food and Nutrition Policy. Assure DPEM strategies and activities incorporated into district development plans as also incorporated into related budgets. NCA23 X X MOH SCF&NSC MIGEPROF MININFRA MINEDUC DP Assure NFNP and NFNSP are factored into new sector development programmes and assure full implementation. NCA X X X X X Social cluster Development partners Develop a targeted policy briefs and advocacy tool to use for resource mobilization. SD1 Act 115 X X X SCF&NSC SCM DP Provide policy briefs on NFNP Implementation status and resources needed to mobilize resources from Development Partners using senior policy officers and other national and SD1 Act 115 X X X X X SCF&NSC SCM DP 22 SD : Strategic Direction 23 NCA : No cost anticipated 47 Key activities CR 201 4 201 5 201 6 201 7 201 8 Responsible Partners Budget (RwF x’000) international channels. Assure NFNP coordination structures give priority to mobilizing resources. NCA X X X X X SCF&NSC SCM DP Promote allocation of specialist positions national and district each level in the health system including strengthening the Nutrition Unit of the Ministry of Health and where appropriate in Social Cluster Ministries. HSSP III X X X X X MOH Districts SCM DP 25,784 Build the capacity of key government actors in advocacy and social mobilization for an effective and efficient implementation of the National Food and Nutrition Strategic Plan X X SCF&NSC SCM DP 53,694 Strategic Direction 2: Prevention of Chronic Malnutrition Specific objective and expected outputs The specific objective for this Strategic Direction is to prevent stunting in children under two years of age. Expected outputs are: 1st 1000 Days Programme activities are implemented nationally District Plans to Eliminate Malnutrition are integrated, effectively strengthened and implemented The 1000 Days Community based programme is strengthened The monitoring and evaluation framework for Strategic Direction 2 is found in Annex 1 Rationale The second strategic direction of the NFNP addresses what is viewed in the EDPRS 2 as the most serious food and nutrition problem facing the country. This strategy aims to lower the 48 prevalence of stunting over a five year period. It includes linkage with most other strategies of the NFNP. Many interventions of the more sector specific strategies are also brought into this strategy in modified ways to support national, district and community level actions aimed at lowering the prevalence of chronic malnutrition in children. The cross linkage is essential for successful implementation because stunting prevention is recognized as being linked with more than 20 existing or planned interventions in Rwanda and many more home practices in areas of nutrition, household food security, social protection, hygiene and sanitation, and infection prevention and treatment. Interventions affecting the health and nutrition of the pregnant woman are linked as well because these stunting can be also be caused or contributed to by poor gestational growth and low birth weights. (See Figure 5) National level 1000 Days in the Land of 1000 Hills Campaign The first of three main interventions under this NFNP strategy are a national campaign “1000 Days in the Land of 1000 Hills.” This intervention, initiated by the Prime Minister in 2013, aims to introduce the problems and solutions surrounding child stunting to the nation. The use of the “1st 1000 Days” theme promotes the importance of growing to a normal height during the 1st 1000 days of life - as an achievement that affects a whole lifetime. Initial national campaign messages focused on the importance of stunting prevention, the multiple causes of stunting, the impact of child stunting at individual, family and national levels, services and practices that prevent stunting and the need for everyone to become involved for their new children’s sake and to support this national objective. Figure 5: Services, Interventions and Practices that help prevent stunting during the 1st 1000 Days 49 The campaign requires active collaboration and support from each Ministry of the Social Cluster Ministries. Many Ministries need to involve staff through their work and as family members, media activities and promotion through Umuganda nationally. Where possible, services contributing to prevention of child stunting in health, sanitation, nutrition, agriculture, education and social protection interventions should be co-branded with the 1st 1000 Days logo and themes. As the campaign becomes successful in creating an enhanced value for women and young children during this period of life, the co-branded interventions will gain addition importance and increased demand. Refocused and strengthened District Plans to Eliminate Malnutrition (DPEM) and District Food and Nutrition Steering Committee (DF&NSC) While District Plans to Eliminate Malnutrition need to continue to cover a wide range of problems and solutions for each district, they also need to be refocused to put much greater emphasis on the prevention of child stunting. Because chronic malnutrition is multi-causal and the strategies needed to effectively combat the problem include many interventions, this refocusing should be effective in dealing with many nutrition and household food security problems facing many of the districts. The NFNP notes that acute malnutrition is itself a major cause of chronic malnutrition and stunting. Strengthened emphasis on stunting prevention should not neglect continued promotion of active identification and outpatient or inpatient management of cases of severe or moderate acute malnutrition. Each DPEM needs to place significant emphasis to the prevention of stunting in children under two years. Promotion from the national campaign, while a highly important component of Strategic Direction 2 will not be sufficient to rapidly reduce child stunting as called for in EDPRS 2. The NFNP recommends District Administrations increase multi-sector participation to include social protection staff and field workers to increase linkage between nutrition and household food security interventions and the most vulnerable. Coordination is required to strengthen the DPEM and adjust these plans, assure all major problems are covered and to effectively facilitate “1st 1000 Days Community Based Food and Nutrition Programs” (1 st 1000 Days CBF&NP) at village level. A District Food and Nutrition Steering Committee (DF&NSC) is needed to support mayors in planning, facilitating and monitoring the strengthened multi-sector DPEM. Active participation is required from senior and technical staff from MINALOC, MINISANTE, MINAGRI, MINEDUC and MIGEPROF as well other sectors as appropriate. The responsibilities of the District Administration DF&NSC will include effective DPEM planning, implementation support and monitoring. The DF&NSC should assure each participating sector organises their work at sector cell and community level to allow joint community level facilitation responsibilities by CHWs, MINAGRI extension staff and MINALOC social protection staff, National Women’s Council Village Committee Chairpersons and village Chiefs. 50 Regular DPEM reporting should include information on performance and constraints in both sector specific and joint activities at sector, cell and village levels. An essential activity of DF&NSC is to support District Administration in fully integrating the DPEM into District Development Plans. Village level: “1st 1000 Days Community-Based Food and Nutrition Programs” Village level is where the objective of preventing child stunting will be achieved. The strengthened DPEM and increased multi-sector involvement should provide the technical and resource support needed to facilitate effective implementation of 1st 1000 Days CBF&NP to prevent stunting and to address other nutrition and household food security problems. This will requires, at minimum, continued promotion of breastfeeding, more appropriate dietary intake” (nutrient dense food, micronutrients) for pregnant and lactating women and children who have reached age of complimentary feeding, provision of appropriate health care for all pregnant and lactating women and for infants and young children. To achieve this will require significant additional efforts in promoting key services and effective social and behavioural change communication. In many cases, especially for the most vulnerable, this may also require helping families learn how to secure and properly use nutritious foods. Interventions in the 1 st 1000 days CBF&NP should also include community based interventions to improve essential new born care, management and referral of preterm neonates or neonates with intra-uterine growth retardation (IUGR). The broader range of these topics may include kitchen gardens, MIYCN, antenatal care, hygiene, food preparation, use of treated bednets, social protection services, cooking demonstrations, food preservation, micronutrient nutrition, de-worming, and other services and practices that help preventing stunting. Early childhood stimulation and care is also important. Rapid operationalisation of the 1 st 1000 Days CBF&NP and expansion to national scale is made possible because they build on existing food and nutrition activities that include monthly community-based growth monitoring and promotion. These activities should be retained but adjusted as needed to better balance the priority given to child measurement and referral of suspected acute malnutrition cases, with MIYCN promotion and counselling, educational and demonstration activities, nutritional care for sick children, health care services, home food security techniques, social protection related topics and important practices to improve early childhood development and care. Linkage among the National 1 st 1000 Days Campaign, the strengthened DPEM and the 1st 1000 Days CBF&NP should be monitored at national level. More operational monitoring and appropriate intervention adjustment needs to be carried out at the level of districts, sectors, cells and villages. 1st 1000 Days Projects and related efforts began in 10 Districts in 2013, supported by funding and technical assistance from Development Partners. The strategies of the MINAGRI Nutrition Action Plan were expected to begin implementation later that year. These projects 51 and other models at district, sector, cell and community levels should inform and help guide rapid expansion of DPEM with a major focus on prevention of stunting toward national level. Implementation Priorities of Strategic Direction 2 Reducing chronic malnutrition in children under two years of age will be treated as urgent based on the magnitude of the problem and the explicit EDPRS 2 requirement that child stunting be substantially reduced from 2010 levels of 47% among children under 2 years of by 2018. Many actions in the NmSEM were directed toward this problem and it was a key element in all DPEM. This will make strategy implementation mainly a problem of introducing and facilitating adjustments needed to address gaps, improve and better focus decentralized activities at district, sector and cell levels. Acceptance of full NFNP co-ownership by MINALOC, MINISANTE, MINAGRI and active participation by MIGEPROF will contribute to strengthening DPEM integration into District Development Plans and budgets and broader participation for technical support and monitoring the strategy. Participation by frontline workers, from at least three ministries in all districts with additional support from NGOs in many districts will add potential to the effectiveness of community based activities. The NFNSP requires that existing protocols and guidelines for Community Based Nutrition Programmes (CBNP), be adapted, strengthened and expanded to guide 1 st 1000 Days CBF&NP. Implementation orientation on 1 st 1000 Days CBF&NP will be an important priority as new resources become available. This orientation will need to be for all health staff including particularly CHWs, as well as front line staff of MINAGRI, MINALOC social protection staff, and MIGEPROF NCWVC chairpersons. Joint efforts will be needed both to increase regular participation in 1 st 1000 Days CBF&NP and expand the range of activities, knowledge and skills that can be used by families and communities to prevent stunting. The 1st 1000 Days CBF&NP will be flexible in its approach and benefit from modelling of effective activities being developed in the districts with established collaboration with NGOs, the One UN 11 and others with internationally donor support. Another channel for support to building effective 1 st 1000 Days CBF&NP should be linkage of these programmes with the many interventions packages in the other strategic directions of the NFNSP. Particularly important are links to interventions in Strategy 3 that focus on improving household food security for vulnerable farming families. Similarly 1 st 1000 Days CBF&NP will benefit from linkage to the interventions in Strategy 4 that focus on the MINISANTE programmes to preventing and m managing all forms of malnutrition and break the linkage between malnutrition and disease. These interventions include active identification of acute malnutrition, MIYCF and micronutrients well as others outlined under Strategic Direction 4. These linkages will be complemented by the keen interest of Development Partners in 1st 1000 Days programme activities. 52 Multisector leadership, coordination and participation as well as community participation will be required to make the effective adjustments and new activities needed to reduce child stunting through decentralized planning and community based activities. Simple and practical monitoring systems and need to be set up to increase the range of available, acceptable and useful information and activities that can be used to more effectively surround core child growth monitoring and enhance regular 1st 1000 Days activities in villages across the country. These factors are expected to rapid development and initial implementation of Strategic Direction 2 that will be followed by continued community participation and improvement. Active, practical monitoring of multi-sector support will be important. As a frontline personnel from different sectors join together to facilitate, the range of useful information and activities that promote and demonstrate how to improve nutrition and household food security will become a more integral part of monthly activities to monitor child growth at community level. Community awareness about stunting and the knowledge and skills on how to prevent it should increase. The demand for community based activities will be further supported by and the 1000 Days in the Land of 1000 Hills national campaign and determination at all levels to prevent child stunting. Expected outputs and Key activities Key Outputs and Activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) Output: Families and Officials across Rwanda know and give value to 1 st 1000 Days Create national awareness on First 1000 Days around 1st 1000 days through national mass media, district media, organizational and non-formal channels. 1000 Days Campaign Strategy X X X PMO SCM DP 132,696 Effectively communicate the knowledge on the services and practices needed to protect children from stunting through a multichannel mix (mass, group and interpersonal) and formal education for families and caregivers 1000 Days Campaign Strategy X X X SCM Districts DP 218,949 53 Key Outputs and Activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) throughout the country. Ensure that repeated and strengthened messages on key services to families aimed at their consistent and correct use to prevent stunting in children <2 years. 1000 Days Campaign Strategy X X X SCF&NSC DF&NSC DP 711,252 Ensure production and dissemination of repeated and strengthened messages on key practices to families promoting their acceptance and permanently adoption to prevent stunting in children <2 years. 1000 Days Campaign Strategy X X X SCF&NSC DF&NSC DP 995,222 Adapt messages produced by the campaign and supporting written and visual materials (booklet, fact sheets, etc.) to integrate with and support 1st 1000 Days CBF&NP activities 1000 Days Campaign Strategy X X X SCF&NSC DF&NSC DP 331,740 Assure active identification and management of cases of acute malnutrition are priorities of 1st 1000 Days CBF&NP. 1000 Days Campaign Strategy X X X MOH DF&NSC DP 16,587 Output: Districts have well formulated operational, multi-sector plans to eliminate malnutrition (DPEM) that are integrated into District Development Plans. These DPEM focus on awareness and behaviour change provision of appropriate health services, access, availability and correct use of nutritious food consistent with the national 1st 1000 days approach targeting parents and families including vulnerable households 54 Key Outputs and Activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) Orient local administrative authorities, (agriculture offices, local government officers working in Social Protection areas, health officers and CHWs) along with other partners to new priority and increased multisector responsibility for DPEM development, facilitating and monitoring 1st 1000 Days CBF&NPs across the district. X X SCF&NSC DF&NSC SCM DP 193,829 Formulate or re formulate DPEM giving priority to the 1st 1000 day technical package. X X DF&NSC SCM DP 125,641 Complete /adapt the District 1st 1000 Days CBF&NP facilitation and monitoring protocol X X SCF&NSC DF&NSC SCM DP 7,997 Mobilize additional resources for the implementation DPEM and 1st 1000 Days CBF&NP actions plans; NCA X X X X X SCF&NSC DF&NSC SCM DP Develop on annual basis 1st 1000 Days CBF&NP multisector action plans. X X X X X DF&NSC DP 901,060 Develop sector and district level monitoring systems including simple but dynamic data display and use of X X DF&NSC SCF&NSC DP 79,067 55 Key Outputs and Activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) RapidSMS. Share lessons learned from DPEM implementation with other districts on a regular basis. SD7 X X X X DF&NSC SCF&NSC DP Output: Monthly 1st 1000 Days Community Based Food and Nutrition Programmes with monthly sessions effectively balance anthropometric tracking with a wide range of activities and discussions on practices and services that can help prevent stunting. Organize and conduct monthly 1st 1000 Days CBF&NP activities including growth promotion activities and IEC discussions with topics covering a full range of interventions related to prevention of stunting with participation from all pregnant women and families with children under two (and under five) to participate – emphasis on inclusiveness including most vulnerable X X X X X DF&NSC Communities Front line workers from MINISANTE, MIINAGRI, MIGEPROF, MINALOC DP 784,895 Design and implement at household level promotional activities including kitchen garden, small animal husbandry and production of staple foods. SD3 X X X X X DF&NSC Front line workers from MINISANTE, MIINAGRI, MIGEPROF, MINALOC DP Ensure that 1st 1000 Days CBF&NP is linked to agricultural household food security programmes and X X X X X DF&NSC DP 114,280 56 Key Outputs and Activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) services and MIINAGRI staff and agricultural promoters join in facilitation. Ensure that 1st 1000 Days CBF&NPs are linked to health services and practices addressing and preventing malnutrition and MINISANTE CHWs and other sector staff join in facilitation X X X X X DF&NSC DP 114,280 Ensure that 1st 1000 Days CBF&NP is linked to family services addressing and preventing malnutrition and MIGEPROF persons join in facilitation X X X X X DF&NSC DP 114,280 Ensure that 1st 1000 Days CBF&NP is linked to social protection services to assure vulnerable families and individuals are not left out and MINALOC social protection staff joins in facilitation. X X X X X DF&NSC DP 114,280 Strategic Direction 3: Improving Household Food Security Note: Major intervention areas of this strategic direction are adapted from strategies and activities of the Nutrition Action Plan (July 2013) that was developed in support of the National Multi-sector Strategy to Eliminate Malnutrition (2010-2013) Plan to MINAGRI which is a co-owner of the NFNP. 57 Specific Objectives and expected outputs The specific objective for this strategy direction is to strengthen, expand and promote services and practices that result in household food security year round for the full population. Household food security has improved as measured by fewer families having problems in accessing the foods needed for a healthy diet throughout the year. Households nationwide have greater knowledge and skills related to producing or obtaining, preserving, processing, preparing and feeding high quality foods and meals needed for healthy complementary feeding and a healthy diet for the pregnant women and other family members. The monitoring and evaluation framework for Strategic Direction 3 is found in Annex 1 Rationale Note: This strategy is adapted from existing programmes and the Nutrition Action Plan of the MINAGRI which is a co-owner of the NFNP” 24 The strategic direction recognizes that substantial further reductions in malnutrition and particularly chronic malnutrition among children under two years of age will not be achieved in an equitable manner unless effective interventions address the 21% of households that remained food insecure in 2012, and the almost 50% that reported difficulty in accessing food sometime during the year. The importance of this strategic direction rests in the potential of raising the nutritional status of agricultural households through improving the quantity and diversity of food they produce and promoting practices that result in more nutritious meals for the family and, in particular better complementary feeding practices. Home gardening can improve access to vitamin rich vegetables and cows and small livestock holding can increase the availability at household level of nutrient rich products including eggs and meat. The NFNSP recommends intervention packages that combine promotion and training around improved agricultural products with training and demonstrations aimed at nutrition education. This approach has been more successful in improving diets than stand-alone promotion of agricultural interventions. The agricultural extension service system offers a valuable communication platform to deliver food production, food use and nutrition-improvement knowledge to farm families. Such a channel will also reach the families’ men, who usually control household resources but share less responsibility for the nutritional and health well being of children. 24 MIINAGRI Nutrition Action Plan, July 2013 58 The NFNSP recommends that MINAGRI continue and expand existing MINAGRI interventions including the GIRINKA, the One-Cow-per-Poor-Family Programme, establishment of school gardens, and homestead gardens with a view toward scale up and with effective linkage to nutrition and household food security learning objectives. The provision of subsidized fertilizer and free seed as part of the Crop Intensification Programme (CIP) should target vulnerable families and promote improved kitchen gardens and small livestock with increased emphasis on their potential to improve dietary variety including protein availability and micronutrients. These activities should also be promoted as a pathway to increased income for vulnerable families. In addition to existing programmes the NFNP recommends and supports new and strengthened interventions outlined under the strategic objectives of the NAP. These include the following: Food Security and Nutrition Monitoring System to regularly monitor food security and nutrition in Rwanda and the strategic grain reserve for use in preventing food shortages and in emergencies. Key interventions that increase and diversify household food production including coordination of agricultural outreach activities to vulnerable households in collaboration with health facilities. These include establishment of village nurseries for fruit and agroforestry trees, support for homestead gardens and small livestock through Farm Field Schools that are composed of vulnerable households, and establishment of model nutrition gardens at village level. Interventions to improve nutrition-related agricultural knowledge/practices of households including preparation and dissemination of nutritious local recipes, provision of small-scale storage and processing technology and technical assistance in food processing, preservation and utilization to vulnerable households. Capacity building from MINAGRI staff through "agriculture for nutrition" modules for NUR and Higher Institute for Agriculture & Polytechnics Interventions to support income generating capacities of food and nutrition insecure households through cost sharing arrangements that promote agro-processing and small-scale agricultural technologies. Technical and financial assistance to vulnerable households in greenhouse farming and commercial vegetable and fruit production, and support for scaling up the One Acre Fund model in the most vulnerable Districts. Interventions to support improved availability, affordability and quality of nutritious food including extension and input support to producers of bio-fortified bean and maize seeds and sweet potato vines as well as communication campaigns to promote planting and consuming of bio-fortified foods, the benefits of milk consumption for children. Support for entrepreneurs to develop innovative milk products and packaging. 59 Interventions to support improved nutritional impact of social transfer schemes linked to the agriculture sector that include a protocol for high priority agricultural interventions and good agricultural practices that can help fight stunting. Training of Rwanda Agriculture Board (RAB) staff and agricultural village promoters in participating in and facilitating 1st 1000 Days CBF&NPs Preparation of a common framework for engagement (CFE) for school feeding Interventions to support for improving governance of food and nutrition security including quarterly progress reports against the strategy (NAP), the National Food and Nutrition Strategic Plan and relevant action plans, Conducting of Food and Nutrition Security Monitoring (FNSM) rounds Comprehensive Food Security and Vulnerability Analysis and Nutrition Surveys. (CFSVA/NS) Many of the interventions outlined here should be included in DPEM and closely linked to the 1st 1000 Days CBF&NP. This linkage should include active and regular participation by MINAGRI extension staff and agricultural promoters in the monthly gatherings of pregnant women and families with young children at community level. Children’s growth will be monitored with the help of CHWs, and MINAGRI staff as well as others should facilitate activities and demonstrations that focus on how better farming, better crop preservation, better food preparation and other agriculture related can improve household food security and nutrition so child stunting is prevented. Participation of MINAGRI staff and related frontline persons will significantly broaden the range of expertise available in these activities and should improve their value to community members beyond what can be facilitated by CHWs alone. Implementation Priorities of Strategic Direction 3 Implementation of this strategic direction to improve household food security will be affected substantially by human resources and funding available through the MINAGRI and development partners. Most interventions in this strategy are based on existing MINAGRI models and programmes. The degree and pace of scale up will be a focus of implementation planning and management. Linkage and the need for MINAGRI and technical staff at district level and lower levels to actively participate in 1st 1000 Days CBF&NP activities will be important. This participation should allow communities and households across the country to be reached, at least with the knowledge and promotional elements of Strategy 3 interventions. Strategy 2 participation will provide MINAGRI with national media support and nationwide community based channels that can be used to promote and help demonstrate improved techniques and practices that can improve household food security. Concurrently, these and additional practices will be introduced and promoted more comprehensively through specified Strategy 3 MINAGRI implementation plans. Improving the linkage between the household food security interventions and social assistance programmes will be undertaken at national and decentralized levels. At national level MINAGRI will work with MINALOC and MINISANTE to improve social protection 60 targeting and “graduation” indicators. At decentralized level targeting appropriate interventions will be well targeted to highly vulnerable households. Expected Outputs and Key Activities Key activities CR 2014 2025 2016 2017 2018 Responsible Partners Budget (RwF x’000)25 Output: Households increasingly diversify their food production Coordinate with Health Centres and MINALOC for agricultural outreach activities to vulnerable households NAP SO1 X X X X X MOA MINALOC MINISANTE DP Establish village nurseries for fruit and agro forestry trees NAP SO1 X X X X X MOA MINALOC MINISANTE DP Support development of homestead garden Farm Field Schools that include vulnerable households NAP SO1 SOI X X X X X MOA MINALOC MINISANTE DP Support development of small livestock Farm Field School that include vulnerable household NAP SO1 X X X X X MOA MINALOC MINISANTE DP Establish of model nutrition gardens at village level NAP SO1 X X X X X MOA MINALOC MINISANTE DP Provide food to very vulnerable groups (community kitchen programs) NFNP X X X X X MINALOC DP (WFP) Output: Improve nutrition-related agricultural knowledge/practices of households Build staff capacity through preparation of "Agriculture for Nutrition" modules for NUR, Higher Institute NAP SO1I 2 X X MIINAGRI MINEDUC DP 25 Strategic Direction 3 which draws many activities from the MINAGRIC Nutrition Action Plan was being costed through a separate exercise and the results will be incorporated into the NFNSP when that exercise is completed. 61 Key activities CR 2014 2025 2016 2017 2018 Responsible Partners Budget (RwF x’000)25 for Agriculture & Polytechnics Provide small scale storage and processing technology to vulnerable households NAP SO1I NAP X X X X X MIINAGRI DP Prepare in Kinyarwanda 'Book of nutritious local recipes' and disseminate nationally NAP SO1I SO2 X X MIINAGRI MINISANTE MINALOC DP Provide technical assistance in food processing, preservation and utilization including vulnerable households NAP SO1I X X X X X MIINAGRI MINISANTE MINALOC DP Prepare and conduct workshop and Aide Memoire for MIINAGRI staff on good agricultural practices to fight chronic malnutrition NAP SO1I X X MIINAGRI MINISANTE DP Train RAB-staff and agricultural village promoters in 1st 1000 Days CBF&NP NAP SO1I X X X X X MIINAGRI MINISANTE MINALOC DPS DP Contribute to updates of 1st 1000 Days CBF&NP Planning, protocol, modules and booklets X X MIINAGRI MINSANTE MINISANTE MINALOC DP Arrange regular participation of MIINAGRI staff as joint facilitator in 1st 1000 Days CBF&NP monthly activities X X X X X MIINAGRI MINISANTE MINALOC DPs Income generating capacities of food and nutrition insecure households support Support PPPs (cost-sharing arrangements) for promoting agro NAP SO3 X X X X X MINAGRI DPs 62 Key activities CR 2014 2025 2016 2017 2018 Responsible Partners Budget (RwF x’000)25 processing and small-scale agricultural technologies Provide technical & financial assistance to vulnerable households in greenhouse farming NAP SO3 X X X X X MINAGRI DPs Provide technical & financial assistance to vulnerable households in commercial vegetable and fruit production NAP SO3 X X X X X MINAGRI DP Support up scaling of One Acre Fund model in the most vulnerable Districts NAP SO3 X X X X X MINAGRI DP Bank Availability, affordability and quality of nutritious food improved Provide extension and input support to producers of fortified beans and maize seeds and sweet potato vine NAP SO4 X X X X X MINAGRI DP District Implement national campaign for planting & consuming bio fortified foods NAP SO4 X X MINAGRI DP District Publicize the benefits of milk NAP SO4 X X X X X MINAGRI DP 63 Key activities CR 2014 2025 2016 2017 2018 Responsible Partners Budget (RwF x’000)25 consumption for children District Support entrepreneurs to develop innovative milk products and packaging NAP SO4 X X X X X MINAGRI DP Private sector Increased access to and use of appropriate food for the most vulnerable households Households of Ubudehe categories 1 and 2 targeted for nutritious complementary food during 1st 1000 Days periods. X X X X X MINALOC MIINAGRI Districts DP Households of Ubudehe categories 1 and 2 targeted for direct cash transfers during 1st 1000 Days periods. X X X X X MINALOC MIINAGRI Districts DP Small livestock and seeds to Ubudehe categories 1 and 2 during their 1st 1000 Days periods. X X X X X MINALOC MIINAGRI Districts DP Male household members of Ubudehe household category 2 targeted for with public works X X X X X MINALOC MIINAGRI Districts DP 64 Key activities CR 2014 2025 2016 2017 2018 Responsible Partners Budget (RwF x’000)25 during the 1st 1000 days periods. Governance of food and nutrition security enhanced MINAGRI District staff actively participates in District Food and Nutrition Steering Committee developing DPEM with links to DPEM to MINAGRI activities X X X X X DF&NSC Report quarterly progress against NAP, NFNSP and other relevant plans. NAP SO6 X X X X X DF&NSC MINAGRI DPs Prepare standard form for MINAGRI projects to report contributions to NAP NAP SO6 X MINAGRI Prepare standard form for ASWG members to contributions to NAP report NAP SO6 X DF&NSC MIINAGRI Conduct Food and Nutrition Security Monitoring (FSNM) rounds NAP SO6 X X X X X MINAGRI DP Conduct Comprehensive Food Security and Vulnerability NAPSO6 X X MINAGRI NISR DP 65 Key activities CR 2014 2025 2016 2017 2018 Responsible Partners Budget (RwF x’000)25 Assessment & Nutrition (CFSVA/NS) surveys Strategic Direction 4: Prevention and management of all forms of malnutrition Specific Objectives and expected outputs are The specific objective for this strategic direction is to prevent and manage all forms of malnutrition. Low prevalence of severe acute malnutrition is sustained and further lowered through active identification and management and preventive services and widespread use if innovative technologies (RapidSMS). MIYCN with has been strengthened through capacity building at all levels with added emphasis on optimal complementary food and feeding practices and the nutrition of pregnant and lactating women resulting in better nutrition for these groups. Feeding of children who are sick has improved. Micronutrient powders are widely available and used to fortify complementary foods in the homes Biofortified crops (beans, sweet potatoes, etc.) are widely available and used and Nutrition of the sick child is effectively promoted through IMCI. The prevalence of anaemia in children is lower in accordance with the objectives set in the HSSP III. The prevalence of anaemia in pregnant women is lower in accordance with the objectives set in the HSSP III. Vitamin A deficiency is effectively addressed through multiple strategies All salt in the country is iodized. PLHA and their families are receiving the nutritional support they require and food and nutritional support is more widely practiced in PMTCT. Effective promotion of appropriate infant and young child feeding has contributed to achieving nation targets for PMTCT and PLHA including children and affected families; as well persons with tuberculosis are receiving needed nutritional support. 66 Diarrhoeal disease prevalence among young children has continued to decrease (improved hygiene) and sanitation. Prevention of overweight and obesity has become a priority topic of health promotion and the MINISANTE policy on non-communicable diseases is being actively implemented including Information generation on overweight, obesity and nutrition related non communicable diseases. The monitoring and evaluation framework for Strategic Direction 4 is found in Annex 1 Rationale Strategic Direction 4 includes the key food and nutrition interventions that are primarily the responsibility of the MINISANTE. These address acute malnutrition, promoting and addressing weaknesses in maternal Infant and young child nutrition (MICYN), micronutrient deficiencies, nutrition and HIV/AIDS, hygiene and sanitation and the prevention and control of nutrition-related non-communicable diseases. Many of these factors are direct or indirect causes of stunting. Acute malnutrition Acute malnutrition is recognized in the NFNP both as a dangerous condition in itself and also as a major contributor to stunting among children under two years of age, To assure continuation in trends showing lowered prevalence of acute malnutrition and to achieve the MDG of 2.5% in 2014 and the HSSP III target of 2.5% in 2017 this intervention area includes a set of closely linked activities. The NFNSP calls for activities supporting active identification and effective management of cases to continue. These include: growth monitoring, promotion and counselling on MIYCN, improved feeding of a sick child, community IMCI, annual community level mass screening of children under five years, and effective application of the national Protocol for the Management of Acute Malnutrition. The NFNSP promotes sustaining these interventions and closely linking them to the 1st 1000 Days CBF&NPs. This intervention package also calls to improving supplies and logistics and continuous capacity- building of health care providers at health facility level (HC&DH) to treat and refer cases with SAM. Maternal, Infant and Young Child Nutrition Maternal, Infant and Young Child Nutrition (MIYCN) promotion and support is an intervention package that includes improving nutrition during pregnancy and lactation, early and exclusive breastfeeding, and improved complementary feeding. These will continue to be important activities for CHWs and al health care workers during 1st 1000 Days CBF&NP. MYICN will be reinforced during ante natal and post natal care visits, during health facility birth stays and throughout the first two years of life by CHWs during regular home visits and 67 health facility based staff. Establishment of workplace for breastfeeding (exclusive breastfeeding should also be promoted). Key indicators regarding MIYCN will remain important components of RDHS and CFSVA/NS. Micronutrient interventions Micronutrient interventions will be implemented through several sets of activities in order to effectively address specific micronutrient issues and distinct target groups. Delivery channels for Vitamin A supplement distribution among children under five and lactating women will be modified and strengthened as conditions allow. The prevention of iodine deficiency will continue to be a priority through monitoring to assure that all salt is iodized and that the population does not have lower than normal levels of iodine26. Existing regulations will be modified as needed. Iron and folic acid supplementation for pregnant women will be substantially strengthened because of persistently low levels of compliance and high anaemia among pregnant women. De-worming activities should also be continued. New strategies to reach children 6-24 months of age with sufficient iron is a NFNP priority because of the extremely high levels of anaemia in this age group (68%) and the potentially negative impact on health and cognitive development. Successful large scale trials of in-home fortification of complementary foods using small sachets of micronutrient powders will be scaled up. A “National Plan for the Reduction of Iron Deficiency Anaemia” will be developed and implemented. Promotion of fortified staples will continue to be promoted as will local production of high quality fortified foods that can supplement families who are managing cases of moderate acute malnutrition and that can provide needed nutritional support for PLHIV and families highly vulnerable to acute malnutrition The scope of high quality food supplements use is expected to accelerate and expand because of recent Government commitment to mobilizing funds to support high quality, micronutrient fortified supplementary food for nutritionally vulnerable children under five years and, pregnant and lactating women in Ubudehe 1 and 2. Nutrition and HIV/AIDS In the area of nutrition and HIV/AIDS the NFNP recommends that the nutritional state of PLHIV and persons with tuberculosis be strengthened and sustained through interventions that closely correspond to national programme recommendations. PMTCT should be addressed through continued promotion of exclusive breastfeeding and introduction of healthy complementary foods. At the appropriate time, supplemental food and careful monitoring for HIV positive mothers is recommendation in order to prevent the often fatal consequences of acute malnutrition among children over six months living with HIV. 26 As measured through surveys of urinary iodine level. 68 Hygiene and sanitation promotion Further improvements and sustaining effective hygiene and sanitation promotion is needed using primarily community level activities in rural areas and improved solid waste management and promotion in towns and urban areas. The NFNP recommends that in this intervention area which is managed by the Environmental Health Service and also by MININFRA should be well linked with 1st 1000 Days CBF&NP. The NFNP emphasis on breaking the synergy between infection and malnutrition requires well planned and promoted activities that focus on the hygiene in relation to infants and children too young to use a latrine or care for their own cleanliness. The difficult hygiene issues related to preventing faecal – oral transmission of infectious bacteria from infants to themselves and from infants and young children to others needs additional emphasis, promotion and operational research. Diet related non-communicable diseases Prevention and management of diet related non-communicable diseases is an intervention area that requires attention because of the increasing prevalence of overweight and obesity, particularly in urban areas. The growing concern and costs related to cases of Type II diabetes and other NCDs such as hypertension that are linked in part to nutrition require monitoring and also a strategic plan for prevention as well as care. Lifestyle changes contributing to these problems and strategies to encourage physical activity should be further explored in order to allow effective prevention strategies to be formulated. To address the growing problem of over-nutrition and a general lack of dietary diversity, a set of nationally recommended dietary guidelines should be developed with specific adaptations for groups and life stages having different nutrient requirements. Physical activities should be included as intervention priorities. Recommended levels ofphysical activities for various groups will be provided by the MINISANTE. Prevention of over nutrition is expected to treated prevention as a multisector issue. Implementation Priorities of Strategic Direction 4 Strategic Direction 4 implementation of activities on prevention and management of malnutrition will give priority to continuing, sustaining and strengthening current nutrition improvement programmes implemented by the MINISANTE. Active identification and management of acute malnutrition both through the community based activities of the 1 st 1000 Days CBF&NP and also annual mass screening by CHWs using MUAC as initiated in 2009. Clinic based nutrition services will be strengthened through IMCI, more active referrals of pregnant women for antenatal care and efforts to significantly improve compliance folic acid and iron supplements. Urgent attention will be given to further improving CHW knowledge and counselling abilities related to breastfeeding, complementary feeding and healthy eating during pregnancy. These are areas where current practices by many mothers contribute significantly 69 to child stunting, anaemia and young child morbidity. CHW skills require strengthening of effective counselling in MIYCN. This strategic direction will be carried out through a range of activities at community, district and national levels. To better address micronutrient deficiencies the work required include relatively diverse strategies that will be carried out simultaneously and range from fortification of staple foods and commonly used condiments (oil, wheat flour, rice salt,) and targeted supplementation (Vitamin A, Iron and Folic Acid) to in-home fortification of complementary foods with multiple micronutrients powders, to promotion of biofortified beans, sweet potatoes, cassava and other crops. Priority work will include a more developing an effective package of interventions for anaemia prevention and control emphasizing women during pregnancy and children 6-23 months. Staple food fortification, which was made mandatory through legislation in 2013, will continue to be promoted as the new regulations come into effect through the National Fortification Alliance. In-home fortification of complementary foods will be widely introduced through 1 st 1000 Days projects in more than 15 districts and distribution channels are modelled and accepted. Improved hygiene and sanitation through community based activities that began in 2010 with support and facilitation by the MINISANTE Environmental Health Services. These activities need to be strengthened in terms of follow-up and expansion in districts that do not have without partner funded technical assistance and support. This well-conceived national effort should be reviewed and adapted to be more effective in urban and town settings. Additional operational research is called for on the special hygiene problems that exist during the first two years of life when the child cannot use the latrine or and others must take care of their hygiene. Critical times and proper hand washing practices of care givers need to be improved through training of care givers, teachers and those involved in school feeding programme. Food and nutrition support for PLHIV and persons with tuberculosis will continue to be supported with a renewed emphasis on linkage to national social protection programmes for highly vulnerable families and individuals and also to support PMTCT provided that advocacy for the needed resources is successful. Rising rates of overweight and obesity and nutrition related non communicable diseases require more closely monitoring as national subsector policies to address these problems are completed and provide implementation strategies to address the broad NFNP objectives. 70 Expected outputs and key activities Outputs and Key activities CR 201 4 201 5 201 6 201 7 201 8 Responsibl e Partners Budget (RwF x ‘000) Output: Continued and strengthened activities to promote lowering of acute malnutrition ( HSSP III target of 2.5% in 2017) Support improvement of the supply chain (logistic, supplies, equipment) - needed for effective management of severe and moderate acute malnutrition according to the national protocol. HSSP II 5.3.1 X X X X X MOH DP CAMERW A 27,837 Build capacity for active identification and management of case of acute malnutrition through health facilities, routine and annual screening, referral and reporting based on growth monitoring and promotion in the 1 st 1000 Days CBF&NP. HSSP III 7.2.5 X X X X X MOH DP 38,166 Build capacity of health care providers at health facilities and CHWs on management of severe acute malnutrition through trainings and supportive supervision. HSSP III 7.2.5 X X X X X MOH DP 791,698 Prevent acute malnutrition through 1st 1000 Days CBF&NP using appropriate, community directed communication strategies and coordinated multi-sector approach. SD2 X X X X X MOH MINAGRI MINALOC DP SCM Output: Maternal, Infant and Young Child Nutrition (MIYCN) effectively promoted Reinforce optimal MIYCN through ante natal care visits, during health facility birth stays and throughout the first two years by CHWs and NFN P SD2 X X X X X MOH DP MIGEPR OFE 71 Outputs and Key activities CR 201 4 201 5 201 6 201 7 201 8 Responsibl e Partners Budget (RwF x ‘000) health care providers at all levels and 1 st 1000 Days CBF&NP. Organize and conduct MIYCN surveys (qualitative and quantitative). X X X X MOH NISR DP 9,227 Output: Improve micronutrient nutrition Conduct gap analysis on Fe+FA supplementation of pregnant women. X X MOH NISR DP 15,046 Develop and initiate “National Plan for the Reduction of Iron Deficiency Anaemia” to prevent anaemia in all age groups and life stages. X X X X X MOH DP 30,139 Improve Fe+FA supplementation coverage and compliance for pregnant women and link to 1st 1000 Days CBF&NP. X X X X X MOH DP MINALO C MIGEPR OFE 497,550 Sustain Vitamin A supplementation of children >5 and lactating women as per WHO recommendations. X X X X X MOH DP MINALO C MIGEPR OFE 485,504 Implement nationally new strategies to reach children 6 24 months of age with sufficient iron. (in-home fortification using MNP and commercially fortified complementary cereals) X X X X X MOH DP MINALO C MIGEPR OFE Private sector 11,948,467 Develop national protocols for prevention and management of Micronutrient Deficiencies. X X MOH DP 15,046 72 Outputs and Key activities CR 201 4 201 5 201 6 201 7 201 8 Responsibl e Partners Budget (RwF x ‘000) Promote and monitor implementation of 2013 regulations requiring staples foods fortification (beginning 2014) X X X X X MOH DP MINALO C Private sector 1,726 Promote wide and rapid adoption and use of appropriate biofortified crops. SD7 Com munic ation X X X X X MINAGRI DP MINALO C MOH MIGEPR OFE Promote growing and use of mushrooms and other highly nutritious crops. SD7 Com munic ation X X X X X MINAGRI DP MINALO C MOH MIGEPR OFE Output: Improved Nutrition for PLHA Strengthen the nutritional state of PLHA and persons with tuberculosis by providing supplementary food to them X X X X X MOH DP MINALOC MIGEPROF E Local NGOs 8,257,081 Building capacity of early identification of malnutrition in PLHA. SD4 Act 412 X X X X X MOH DP MINALOC MIGEPROF E Local NGOs Continue PMTCT promotion through exclusive breastfeeding and ART and introduction of healthy complementary foods at the appropriate time by HIV SD7 Com munic ation X X X X X MOH DP MIGEPROF E Local NGOs 0 73 Outputs and Key activities CR 201 4 201 5 201 6 201 7 201 8 Responsibl e Partners Budget (RwF x ‘000) positive mothers. Provide supplemental food for in need PLHA children over six months at health facility level and careful nutritional monitoring for all HIV exposed children. SD4 Act 441 X X X X X MOH DP Output: Sustained and expanded effective hygiene and sanitation promotion Continue and expand community based hygiene and sanitation promotion through communication approaches. SD7 Com munic ation X X X X X MOH DP MINALO C MINAGR I MIGEPR OFE Reinforce community based hygiene during 1st 1000 days CBF&NP with special emphasis on hygiene related to children 0-2 years through operational research to strengthen activities, demonstrations and communication materials. SD2 X X X X X MOH DP MINALO C MINAGR I MIGEPR OFE Output: Prevention of obesity strategy developed and alliances formed to address growing prevalence of over nutrition and nutrition related non communicable diseases Develop a national strategy for obesity prevention. X X X X X MOH DP 42,740 Create “Rwanda Alliance against Obesity” together with Government, NGOs, RNS, civil society and private sector. X X X X X MOH DP MINALO C MINAGR I MIGEPR OFE MINIYO 6,279 74 Outputs and Key activities CR 201 4 201 5 201 6 201 7 201 8 Responsibl e Partners Budget (RwF x ‘000) UTH Develop Rwanda Dietary Guidelines with adaptations for groups with different nutritional requirements including recommendations for physical activities. X MOH Rwanda Nutrition Associatio n DP 8,295 Strategic Direction 5: Improving food and nutrition in schools Specific objective and expected outputs The specific objective for this strategy is to strengthen nutrition education in schools and higher learning institutions through curricular and extracurricular activities. Expected outputs are: 1. Food and nutrition education has been substantially expanded throughout school curriculum and extracurricular activities. 2. Schools across the country are fostering learning about the “1st 1000 Days” through curricular an extracurricular activities. The monitoring and evaluation framework for Strategic Direction 5 is found in Annex 1 Rationale Strategic Direction 5 of the NFNP concerns improving school feeding food and strengthening teaching and learning around important food and nutrition concepts and skills through curricular and extra-curricular activities. School feeding The first intervention area calls for sustaining and expanding existing school feeding programmes including meals in secondary schools and the Cup of Milk programme for children in pre- and primary schools currently carried out in collaboration with the MINAGRI. The NFNP recommends that emphasis be placed on brining on line and rapidly expanding new approaches to school feeding including the large scale “Home-Grown School Feeding Programme.” 75 Learning about food and nutrition The second intervention area includes expanding and improving food and nutrition teaching and learning. The NFNP recommends that along with other subject areas, the core concepts behind the national effort to prevent chronic malnutrition in children and the national 1st 1000 Days campaign to prevent be more fully integrated into curriculum, at appropriate levels. This will help assure that when school students become adults and parents they are well aware of these concepts and many of the services and practical skills that can protect a pregnant and lactating women and her child throughout the 1st 1000 day “widow of opportunity.” The 2013-2015 national “1000 Days in the Land of 1000 Hills” communication campaign provides an opportunity to obtain a wide range of relevant materials that should be useful in this area of work. Gardening and small animal husbandry at schools are recommended with emphasis that, in agreement with the 2013 School Health Policy, the first objective of these activities is to enrich student learning about food and nutrition. Improving students’ nutrition through such activities is only a secondary objective. Innovative approaches are encouraged to bring adaptations of these activities to schools in urban areas and towns where schools have minimum land. Nutrition assessment and services The NFNP endorses the Education Sector Strategic Plan and the School Health Policy requirement for regular nutrition and health assessments for all children, to be conducted in collaboration with MINISANTE health facility staff. Schools are encouraged to strengthen and expand follow-up on malnutrition cases, through counselling, health facility referral, and solutions through schools programmes, the family, the community, social protection services and other means. Deworming and Vitamin A supplementation in schools should continue. Implementation Priorities of Strategic Direction 5 Implementation of strategies to improve food and nutrition in schools will be implemented by MINEDUC with collaboration from MINAGRI and MINISANTE. Implementation of interventions to bring nutritious foods to students at all levels is highly challenging because of the high numbers of schools and pupils involved, funding requirements and organizational and logistical issues. Several relatively small scale interventions will be continued and scaled up in phases and this includes demonstration gardens at schools and the MINAGRI funded school milk program. The potential for success in bringing at least one healthy meal to all students at all ages is higher than previously because of completion of the research and comprehensive modelling behind the “Home Grown Feeding” model and is national in scope. Implementation will depend on government and human resources and will most likely include expanded operational testing and adjustment as a preliminary stage. During these periods, many aspects of safe food handling and storage and the importance of hand washing hygiene related to food preparation will need to be developed. Health and nutritional 76 assessments of children in schools as recommended in the School Health Policy are also recommended as an activity to be done in collaboration with local MOH personnel. Improving learning of important and practical food and nutrition related concepts and practices through the curriculum and extracurricular activities for different age levels will also take substantial time and resources to develop and effectively disseminate throughout school systems. Assessments of existing curricular and extracurricular lessons and activities relevant to nutrition and household food security are recommended as an initial priority activity. Development of a “learning package” of lessons and activities that focus on key knowledge areas and essential skills areas closely related to those in window of opportunity called the 1 st 1000 Days to Prevent Child Stunting is highly recommended as a priority. The topics, services and practices important to prevent stunting during the 1st 1000 Days are highly diverse ranging from the importance of good and protection from infection through vaccination, good hygiene, deworming, safe water and use of treated bednets. These should be welcomed topics and activities because they are relevant to the current lives of students and to their futures as adults who will participate in 1st 1000 Days period of their own. Lessons and activities on these topics will continue to be supported by the national media and outreach campaign. There is also strong potential to generate resources from Development Partners to support rapid work in these areas. The MINEDUC is committed to developing comprehensive models that bring more food to children in schools and for further improvements in teaching and learning around concepts of healthy food and nutrition. MINEDUC should receive support from the MINISANTE and the NF&NTWG to effectively and appropriately identify and lay out the main concepts around chronic malnutrition and the importance of the 1st 1000 Days so that they can be developed into effective teaching and learning activities for different aged students. The NFNP recognizes that linkage is required between MINEDUC and MINAGRI on school feeding and learning activities that include growing food including school gardens and small livestock. Development Partners also have useful expertise in these areas that can be used to assist. The linkage between MINEDUC and MINISANTE will be needed if health and nutrition assessments of children become widespread and regular and in the case of student illnesses in schools. Expanding and making more regular these cross sector links at national level will bring needed content expertise to work on improving curriculum and food and nutrition related school activities. Linkages between MINEDUC and other sectors are also needed at decentralized levels where MINEDUC should be an active member of the DF&NSC and development of DPEM. 77 Outputs and Key activities Outputs and Key activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x’000) Output: Food and nutrition education has been substantially expanded throughout school curriculum and extra-curricular activities Conduct curriculum gap analysis focused on key elements of food and nutrition and life skills including 1 st 1000 Days.. X MINEDUC REB, DP 13,800 Develop curricular and extracurricular age appropriate leaning modules and activities expand food and nutrition learning components (urban vs. rural settings to be considered). X X MINEDUC REB MINISANTE MIINAGRI DP 20,408 Produce and disseminate learning materials along with appropriate in service training of teachers on new learning modules/activities. X X MINEDUC DP 30,933 Incorporate food and nutrition learning package into pre-.service training of teachers. X X MINEDUC R REB MINISANTE MIINAGRI DP 30,933 Implement school gardens and “grow areas” as pedagogical tools for learning teaching about food and nutrition. X X X X X MINEDUC MIINAGRI DPs 125,583 Link schools teaching and activities on food SD5 X X X X X MINEDUC MINISANTE 78 Outputs and Key activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x’000) and nutrition with the key concepts, services and practices of the 1st 1000 Days campaign and community based nutrition programmes. Act 513 MIINAGRI MIGEPROF DP Output: The implementation of the School feeding program has been expanded countrywide Expand the “one cup of milk per child” in collaboration with MIINAGRI. SHSP27 X X X X X MINEDUC MIINAGRI 15,697,914 Operationalize and Institutionalize home grown school feeding program. SHSP28 X X X X X MINEDUC MIINAGRI MINALOC DP 20,930,552 Sustain and improve the secondary Boarding School Feeding” model. SHSP29 X X X X X MINEDUC MIINAGRI MINALOC DP 37,423,827 Output: The School health Policy has been implemented Develop programme to screen pre-school and school children for malnutrition. x x x MINEDUC MINISANTE 833,414 Install and/or maintain drinking-water points and hygienic and sanitation facilities. X X X X X MINEDUC MINIFRA 3,139,582 Provide micronutrient supplements (vitamin A) to children under 5 in SD4 X X X X X MINEDUC MINISANTE 27 SHP : School Health Strategic Plan 28 SHP : School Health Strategic Plan 29 SHP : School Health Strategic Plan 79 Outputs and Key activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x’000) Pre-school. Act434 DP Collaborate with MOH on national strategy to eliminate anaemia target groups, particular girls in secondary school (weekly campaign Fe+FA). X X X X X MINEDUC MINISANTE DP 14,965 Sustain and strengthen deworming of school children. X X X X X MINEDUC MINISANTE DP 457,332 Strategic Direction 6: Assuring food and nutrition in emergencies Specific objective and expected outputs The specific objective or this strategy is to improve food and nutrition sensitivity in emergency preparedness and response”. An early warning system for disasters and preparations for the adequate nutritional care of affected persons are in place. Preparations for prompt and adequate food and nutrition response to a large number of refugees is in place More vulnerable persons among existing refugees are provided with adequate food and nutritional care and support. The monitoring and evaluation framework for this strategic direction are found in Annex 1 6 Rationale Strategic Direction 6 concerns assuring adequate nutrition for persons affected by disasters and for refugees. The NFNP objective is to assure that persons and families affected by disasters and in refugee situation receive a variety of nutrient rich food. The NFNP recommends that emergency preparedness plans be reviewed in relation to the international and national guidelines and that preparedness and response develop contingency strategies for assuring adequate nutritional care on feeding infants and young children, the injured and some elderly. 80 Further strengthening of disaster and refugee preparedness and response are recommended through additional joint planning with the MINISANTE and key Development Partners including UNICEF, WFP, UNHCR and WHO. Links should also be strengthened with donors that can help assure the rapid availability of therapeutic foods for cases of serious acute malnutrition and supplementary rations to support moderate acute malnutrition management. Others with special nutritional needs including HIV positive mothers, PLHA, pregnant and lactating women and children under five years of age should be included in preparedness planning and response. Special attention should be given to children who were breastfeeding but have been separated from their mothers and for children 6-24 months of age who need to receive well prepared complementary foods and require feeding several times per day. NFNP intends through Strategic Direction 6 to provide a base for advocacy and technical assistance for on-going improvement in disaster and refuges preparedness and management planning in the areas of food and nutrition. Such advocacy is expected to help build local capacities and secure national and international resources needed to support improved preparedness and response.30 Implementation Priorities of Strategic Direction 6 MIDMAR is the principle ministry responsible for Strategic Direction 6 which includes additional emergency preparedness work that strengthens the Ministry’s technical agenda and advocacy base for better assuring that nutrition problems do not add unnecessarily to morbidity and mortality burdens associated with these difficult situations. Implementation priority will follow the directions of MIDMARs strategic plan. Concurrent work will be carried out to further improve the scope of emergency preparedness on assuring nutrition and to review nutritional issues of existing refugees. These activities will be followed by recommendations and related advocacy needed to secure the additional resources needed to further improve nutritional responses. Monitoring that includes well selected nutritional indicators will serve as the basis for on-going adjustment and improvements in this area. Expected Outputs and Key activities Outputs and Key activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) Output: An Early Warning System for emergencies is in place Assure an early warning system is established and functions in MIDMAR. X X X X X MIDMAR SCF&NSC DP 66,816 30 Fortified corn-soy blend (CSB) and a Rwanda product of fortified maize grains, soy beans and sorghum called SOSOMA are commonly used for children with moderate acute malnutrition (MAM). A CSB++ is a CSB recipe that is fortified with oil and dry skim milk. 81 Outputs and Key activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) Set up- early warning system data collection mechanisms. X X MIDMAR SCF&NSC DP 44,591 Develop contingency plans with strategies that address nutrition issues during emergency response phase and post-emergency phase. X X X X X MINISANTE MIDMAR SCF&NSC DP 14,505 Strengthen MIDMAR capacities to coordinate nutritional needs in emergencies through production of guidelines and trainings that incorporate nutrition interventions. X X X MINISANTE Districts MIDMAR DP 629 Advocate for broader, nutritionally complete food basket to be provided in emergency situations (staples, ingredients needed for nutritious complementary feeding, necessary vitamins and minerals, supplements for vulnerable). X X X X X SCF&NSC MIDMAR DP 750 Review the emergency plans to ensure diverse foods for special groups (pregnant women, PLHIV, children <2 years). SD6 Act 613 X X X X X MINISANTE MIDMAR DP Develop/strengthen institutional structure and capacity of the National Committee for Disaster Coordination and Management and provincial/district networks to assure priority for X X X SCF&NSC MIDMAR Districts DP 14,611 82 Outputs and Key activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) nutrition. Output: Strengthen prompt and adequate nutrition response in emergency situations. Organize joint planning/ programming with NGOs with comparative advantages in delivering of Disaster Management safety net services (Red Cross and other NGOs) through the Disaster Management Working Group X X X X X SCF&NSC Districts DP 64,732 Ensure that appropriate integrated related nutrition interventions are provided to the people in emergency situations (stunting prevention, micronutrients, disease prevention and case management for acute malnutrition). SD6 Act 613 &616 X X X X X MINISANTE Districts DP Conduct rapid nutritional assessments /nutrition surveys to ensure continuity and appropriateness of supplementary food allocation. X X X X X MIDMAR SCF&NSC Districts DP 20,320 Set up emergency response review system to gather lessons learned on nutrition and feed these into emergency preparedness. X X X MIDMAR SCF&NSC Districts DP 40,936 Establish a rapid information dissemination system to decision makers. X X X MIDMAR SCF&NSC Districts DP 20,783 Build capacity for community-level action for nutrition response in SD6 Act X X X MIDMAR SCF&NSC Districts 83 Outputs and Key activities CR 2014 2015 2016 2017 2018 Responsible Partners Budget (RwF x ‘000) emergency situations. 625 DP Strategic Direction 7: Supporting programmes and services Specific policy objectives and expected outputs The specific objectives for this strategic direction are to improve governance systems and accountability (planning, budget allocation, implementation, communication support and monitoring and evaluation) for improving nutrition and household food security and to assure necessary support for achieving and sustaining the overall strategy. Assure provision of the supportive programmes and services needed for policy implementation of NFNP policy. Needed supplies and commodes relevant to strategy implementation are on hand and well disseminated on a regular basis. DPEM have regular technical support from sector specialists and development partners. Monitoring & evaluation is adequate. data is more accessible and transparent, Operational Researches are conducted Information Sharing systems are in place and functional. Adequate communication support is provided. Human and national capacity building in food and nutrition are progressing. The monitoring and evaluation framework for Strategic Direction 7 is found in Annex 1 Rationale Strategic Direction 7 includes the supporting organizational arrangements and activities needed for effective policy implementation. The NFNP recommends multisector leadership based in the Social Cluster Ministries, with support provided by appropriate coordination mechanisms. Most supplies and commodities needed to support NFNP interventions are cross referenced to the existing policies, programmes and budgets of relevant sector Ministries and Development Partners. 84 Specific supportive intervention areas include: 1. Mechanisms to assure coordination and leadership for implementing the NFNP and NFNSP 2. Assure supplies and commodities not provided through sector specific and multisector strategies (various Ministries, District budgets and Development Partners) that are needed to implement the NFNP and NFNSP are mobilized and secured. 3. Design and implementation of multilevel monitoring and evaluation of NFNSP with integration into Rwanda HIMS, RapidSMS and overall E-Health Framework. 4. Operational research and strategic information sharing at national and district levels to support NFNP and NFNSP implementation 5. Communication support for policy advocacy, resource mobilization, alliance building and to effectively promote and community level social and behavioural change. . 6. Development of a comprehensive national short, medium and long term capacity building plan(s) national expertise requirements in nutrition and household food security along with a strategy for necessary funding. 7. Technical assistance decentralized levels by NFNTWG Task Force Teams. 8. Integration of NFNSP activities into national programmes such as IMCI, HIV, NCDs etc.” Implementation Priorities of Strategic Direction 7 The continuation of existing support services and activities and additional ones will be provided across the strategic directions, specific interventions and strategies of the NFNSP. Effective implementation of these support services will draw primarily upon resources committed by participating Ministries and Development Partners including technical expertise, personnel and organisational services. In some cases additional funding resources will be needed from participating Ministries and Development Partners to implement essential NFNSP support requirements. It is expected that the SCF&NSC will request the NF&NTWG to set up tasks forces and/or teams to assist in developing and carrying out many of these supportive services and activities. The commitment of the Social Cluster Ministries and the Development Partners represented in the NF&NTWG will be a critical factor in successful implementation of the NFNP and the NFNSP. 85 Strategic Direction 7: Outputs Key activities Outputs and Key Activities CR 2014 2015 201 6 201 7 201 8 Responsibl e Partner Budget (RwF x ’000) Output: The Social Cluster of Ministries includes a national Food and Nutrition Steering Committee that helps to coordinate NFNP/NFNSP implementation across sectors and development partners Enhance the capacity of the Prime Minister’s Office and Social Cluster Ministries to facilitate NFNSP multi-sector coordination through set up a Social Cluster Food and Nutrition Steering Committee (SCF&NSC) with co-chairs from MINISANTE, MIINAGRI and MINALOC .and all Social Cluster Ministries represented X PMO SCM DP 84,500 Ensure District Food and Nutrition Steering Committees (DF&NSC) are set up led by MINALOC with active participation by MIINAGRI, MINISANTE, MINALOC (social protection), and MIGEPROF). SD2 Act 222 X PMO SCM DP Build capacity of senior staff of line ministries to facilitate collaboration and coordination of NFNP and NFNSP implementation. X X X SCF&NSC Districts DP 88,695 Conduct biannual NFNSP and DPEN monitoring and adjustment meetings at national, district and sector levels with participating Ministries, Partners and other stakeholders X X X X X SCF&NSC Districts DP 210,912 Organize annual multisector NFNSP planning to develop annual Joint Action Plans for NFNSP coordinated X X X X X SCF&NSC Districts DP 19,663 86 Outputs and Key Activities CR 2014 2015 201 6 201 7 201 8 Responsibl e Partner Budget (RwF x ’000) implementation. Organize annual nutrition sector review meetings and submit reports NC A X X X X X SCF&NSC Districts DP Output: Needed supplies and commodities relevant to strategy implementation are on hand and well disseminated on a regular basis Identify funding sources for, procure, and distribute any additional equipment, supplies and commodities as needed to support NFNSP implementation. X X X X X SCF&NSC Districts DP 3,438 Assure effective use and maintenance of any additional equipment, supplies and commodities required for effective NFNSP implementation. X X X X X SCF&NSC Districts DP 117,544 Output : Monitoring & Evaluation has led to important intervention adjustments, operational research has strategy improvements and important lessons learned are being documented and shared across districts and lower levels Taking existing resources into account develop guidelines for a functional NFNSP monitoring and evaluation system at national, district, sector and community levels (emphasis on 1st 1000 Days) and linkage with Rwanda HMIS, the overall E-Health Framework and other sectors MIS X X SCF&NSC Districts DP 21,257 Implement the NFNSP M&E guidelines and scale up. NC A X X X X X SCF&NSC Districts DP Promote multisector collaboration that assures sector and subsector strategic 14,588 87 Outputs and Key Activities CR 2014 2015 201 6 201 7 201 8 Responsibl e Partner Budget (RwF x ’000) plans of the Social Cluster Ministries each include nutrition and household food security related activities and indicators that can be strong multi-sector information base for decision making. Develop a qualitative information collection system that regularly generates information on success stories related to NFNP implementation. 14,430 Integrate RapidSMS nutrition tracking indicators into 1 st 1000 Days monitoring at all district, sector and community levels. X X SCF&NSC DP 56,528 Strengthen collaboration between research institutions and services providers and other extension workers in food and nutrition research. X X X X X SCF&NSC DP 18,340 Establish and maintain a national/district /sector/community level nutrition and household food security visual monitoring display system(s) for the 1st 1000 days program. X X X X X SCF&NSC Districts DP 42,974 With participation of districts and development partners, set up system that regularly documents and widely disseminates useful lessons learned and best practices linked with NFNSP and 1 st 1000 Days. X X X X X SCF&NSC Districts DP 72,396 88 Outputs and Key Activities CR 2014 2015 201 6 201 7 201 8 Responsibl e Partner Budget (RwF x ’000) Gather information for, produce and disseminate periodic reports and nutrition bulletins. SD7 Act 738 X X X X X SCF&NSC D F&NSC Districts DP Carry out periodic food and nutrition surveys and comprehensive vulnerability assessments. X X SCF&NSC Districts NISR DP 403,745 Further develop food and nutrition surveillance systems countrywide to allow rapid adjustment to programmatic problems and inform on progress toward achieving the NFNP/NFNSP objectives. X X X X X SCF&NSC Districts DP 510,182 Conduct mid-term and final evaluation of the food and nutrition strategic plan. X X SCF&NSC Districts DP 125,069 Output: Adequate communication support is provided for community based promotion and education around key elements of the NFNSP Develop a multisector communication strategy to support all strategic directions of the NFNSP with emphasis on national “1000 Days in the Land of 1000 Hills” campaign NFNS P SD 2 X SCF&NSC Districts DP Strengthen and expand linkage of MINAGRI, MINISANTE and MIGEPROF communication capacities in support of the multisector and joint sector activities of the NFNSP with emphasis on 1 st 1000 X X X X X SCF&NSC District s DP 34,283 89 Outputs and Key Activities CR 2014 2015 201 6 201 7 201 8 Responsibl e Partner Budget (RwF x ’000) Days Design, print and distribute integrated communication support materials. X X SCF&NSC District s DP 45,500 Design, test and disseminate guidelines for conducting communication outreach activities through formal and nonformal, decentralized channels. SD7 Act 745 X X SCF&NSC District s DP Organize and implement communication support and advocacy related media based activities. X X X X X SCF&NSC District s DP 1,972,100 Output: Human resource and institutional capacity building in food and nutrition is progressing Organize multisector, academic, DP team to develop a costed, 15 year “Food and Nutrition National Capacity Building Strategy” and related funding strategy. X SCF&NSC District s DP 28,400 Initiate first phase implementation of the capacity building strategy including key in-service materials development/dissemination related to 1st 1000 Days. X SCF&NSC District s DP 49,723 NF&NTWG task forces develop templates to assist DF&NSC to strengthen DPEM with emphasis on prevention of stunting and 1st 1000 Days CBF&NP. X SCF&NSC District s DP 3,200 90 Outputs and Key Activities CR 2014 2015 201 6 201 7 201 8 Responsibl e Partner Budget (RwF x ’000) NF&NTWG technical assistance teams facilitate and DF&NSC to strengthen DPEM and prepare to assist multisector facilitation and monitoring of DPEM and 1st 1000 Days CBF&NPs SD 2 Act 22 6 SCF&NSC District s DP NF&NTWG technical assistance teams provide assistance as requested by districts related to general or specific interventions in the 1st 1000 Days “package” for 1st 1000 Days CBF&NP. SD 2 Act 22 6 X X X X X SCF&NSC District s DP Recruit additional nutrition staff at district levels. X X X X X Districts SCF& NSC MIFOT RA DP 23,446 Develop training materials and cascade strategy to train health providers, community health workers and other resource people in nutrition and household food security related topics including data analysis and data use. X X X X SCF&NSC District s DP 879,423 Organize and arrange multisector+ Development Partner quarterly supportive supervision visits to districts. X X X X X SCF&NSC District s DP 185,069 Advocate for training of nutritionists in tertiary institutions SD 7 X X X X X SCF&NSC District s 91 Outputs and Key Activities CR 2014 2015 201 6 201 7 201 8 Responsibl e Partner Budget (RwF x ’000) Act 75 1 DP NFNSP activities are integrated into health programmes such as IMCI, HIV, NCDs, etc. SD 7 Act 75 1 MINISAN TE DPs As requested by SCF&NSC, NF&NTWG develops task force to meet and discuss optimum integration of NFNSP and 1st 1000 Days with relevant national programs i X SCF&NSC DP 50 The linkages among all seven strategic directions of the NFNSP are necessary to effectively address the major nutrition problems facing Rwanda in the current period of rapid economic growth and expanded access to basic services. The first six strategic directions include interventions that reinforce different approaches to attack basic, underlying and immediate causes of malnutrition. The DPEM and “1st 1000 Days Community Based Food and Nutrition Programmes” will require added responsibilities and participation of the MINISANTE, MINAGRI, MIGEPROF and MINALOC at District, sector cell and community levels. These expanded responsibilities and participation are in line with the overall missions and objectives in each of these sectors. They focus on effectively promoting services and practices that will result in improvements household food security year round and better nutrition for families while aiming more specifically at the prevention of stunting in young children. Implementation plan and management framework The seven strategic directions of the NFNP are necessarily interrelated in order to address the major nutrition problems facing Rwanda in the current period of rapid economic growth and expanded access to basic services. The first six strategic directions include packages of interventions that overlap. This reflects the need for reinforcing approaches to address basic, underlying and immediate causes of malnutrition. 92 The DPEM and “1st 1000 Days Community Based Food and Nutrition Programmes” require added responsibilities and participation of the MINISANTE, MINAGRI MIGEPROF and MINALOC at District, sector cell and community levels. These expanded responsibilities and participation are in line with the overall missions and objectives in each of these sectors. They are needed to effectively promote services and practices that will result in improvements in household food security year round and better nutrition for families and prevent stunting in young children. Implementing the NFNP will be facilitated by the progress that has been made and by the high priority now being given to solving nutrition and household food security problems from Government and Development Partners. Implementation will also be guided by recent qualitative and quantitative national research and surveys and international research that provide information on the effectiveness, costs, and benefits of relevant food and nutrition interventions. The NFNP implementation priorities also draw from review of national priorities lessons learned around implementation achievements and problems of the 2007 National Nutrition Policy, the National multisector Strategy to Eliminate Malnutrition (2010 2013), the Joint Action Plans to Eliminate Malnutrition (JAPEM) and the District Plans to Eliminate Malnutrition 2011-2013. Plans for NFNP implementation accept the importance and urgency of each strategy and that each intervention addresses one or more of the direct, underlying and basic causes of food insecurity and malnutrition. The NFNP recommends a pragmatic implementation approach that takes into account existing and future resources and human capacities. Policy implementation priorities also take into account the potential effectiveness and coverage scale of the interventions in each strategic direction, their complexity, and the immediacy of the problems they address. Leadership and coordination at national and decentralized Levels Joint NFNSP ownership and implementation responsibility The clear linkage and synergy between household food security, optimal nutrition, and social protection requires a truly multisector approach. Recognition of this includes the Social Cluster Ministries decision to broaden the policy name to “National Food and Nutrition Policy” and this multisector planning document to “National Food and Nutrition Strategic Plan 2013-2018.” Principle ownership and planning and implementation responsibilities were expanded to include the MINALOC, MINISANTE and MINAGRI. Social Cluster Ministries including MINEDUC, MIGEPROF and MIDMAR also have essential NFNSP implementation responsibilities as well. Coordination and leadership National level In order to strengthen the consistency and efficiency of actions undertaken by many sectors and partners, the food and nutrition activities will be coordinated from, at minimum, at 93 central, district level and sector levels. Each level has its specific mission: central level to conceptualize policies and strategies and mobilize resources, provincial level to offer technical services in support of the district level which operationalizes or implements programs and supports as needed those managed by the community. Coordination of overall NFNP implementation at its highest organizational level is in the Prime Minister’s Office through the Inter-Ministerial Coordination Committee (IMCC) that meets quarterly to review progress reports on Food and Nutrition from the Social Cluster Ministries. Coordination of strategies and activities under the framework of the NFNP is the responsibility of the Social Cluster Ministries. A Social Cluster Food and Nutrition Steering Committee (SCF&NSC) inside the Social Cluster will be set up and be co chaired by staff from the three Ministries that co-own the National Food and Nutrition with active participation by other Social Cluster Ministries. This Steering Committee will both advise and report on nutrition and household food security. The SCF&NSC will be responsible for the National Nutrition Food and Nutrition Technical Working Group. The National Food and Nutrition Technical Working Group (NF&NTWG) includes participation from all partners including the Social Cluster Ministries, bilateral and multilateral donors, UN agencies (UNICEF, WFP, WHO, FAO), national/international NGOs, academic institutions, donors and the private sector. Beginning in 2013, the NF&NTWG membership expanded to include members of the ad hoc Household Food Security and Nutrition Working Group that has been set up in MINAGRI to develop a MINAGRI-owned Nutrition Action Plan. (See Figure 6) The NF&NTWG will meet (full membership of smaller task forces) at the request of the SCF&NSC. These meetings will be organized by co-chairs of the working group. The NF&NTWG will provide technical advice and assist in coordinating and organizing national activities and provide technical assistance for decentralized activities. Provincial level will Figure 6: Coordination and Technical Assistance for Implementation of the National Food and Nutrition Policy and Strategic Plan 2013-2018 94 support the policy through provision of technical services including capacity building activities. District level At decentralised level a multisector District Food and Nutrition Steering Committee (DF&NSC) will be set up and under MINALOC and be responsible to the District Mayor. The DF&NSC should include key officers from health (MINISANTE), household food security (MINAGRI), family and gender (MIGEPROF), social protection and early childhood development (MINALOC), sanitation and hygiene (MINIFRA and MINISANTE Environmental Health Department) and education (MINEDUC), planning (MINALOC) and monitoring (MINALOC). The primary functions of the DF&NSC are: 1. DPEM planning, 2. Coordination of sector participation in joint activities, 3. Monitoring implementation of interventions and 4. Assuring fully integration of DPEMs into DDPs including the multisector 1 st 1000 Days Community Based Food and Nutrition Programmes. Sector Level Coordination Sector level administrations will also form Sector Food and Nutrition Steering Committees with similar membership of the DF&NSC to coordinate technical assistance to communities as they refocus and initiate 1st 1000 Days Community Based Nutrition Programmes. Coordinating joint sector participation in providing technical -support to these and other household food security and nutrition related programmes and monitoring them will be the primary responsibility of these steering committees. Technical assistance and funding support will be welcomed from NGOs at each level including those of the community. This layer of coordination may be needed to effectively support village level activities. Joint Facilitation of the 1st 1000 Days Community-Based Food and Nutrition Programme Community based and community managed programmes to help families to learn about and adopt practices that improve household food security and nutrition often require facilitation that includes planning and coordination at district, sector and cell level. To ensure the most vulnerable families participate requires additional work and commitment. “1 st 1000 Days Community Based Food and Nutrition Programmes should include participation by pregnant women and families with young children including those among the most vulnerable. The NFNP recommends that 1 st 1000 Days CBF&NP be implemented across the country. The NFNSP Strategic Direction 2 is the main multisector strategy for carrying this out. At the community level facilitation support should be a joint responsibility of frontline workers in 95 the MINAGRI, MINISANTE and MINALOC (social workers), and MIGEPROF and assistance where possible from MINEDUC headmasters and teachers, NGOs, community leaders, and community level organizations. NFNSP stakeholder roles and responsibilities The Ministries and Government agencies, development partners and the private sector each have necessary roles under the NFNP. Many have responsibilities at both national and decentralized levels. (See Table 2). Table 2: National Food and Nutrition Policy Stakeholders Roles and Responsibilities at National and Decentralized Levels (Government Ministries listed in alphabetical order) Prime Minister’s Office Overall responsibility for the National Food and Nutrition Policy and implementation of the National Food and Nutrition Strategic Plans Social Cluster Ministries Responsibility for effective, coordinated planning, implementation and monitoring of the and National Food and Nutrition Policy and National Food and Nutrition Strategic Plans Set up and use of the multi-sector Social Cluster Food and Nutrition Steering Committee ( SCF&NSC) Ministry of Agriculture and Livestock Resources (MINAGRI) NFNP co-owner and with primary responsible for Strategic Direction 3. Jointly responsibility for Strategic Directions 1, 2, 7. Active collaborator on Strategic Direction 4, and 5. National level Provision of leadership in NFNP implementation as co-owner of the multisector NFNP. Co-chair Social Cluster F&N Steering Committee Collaboration with MINALOC and MINISANTE and other Ministries and the NF&NTWG to elaborate national nutrition Decentralized levels Co-chairmanship of the District Food and Nutrition Steering Committee Collaboration with MINALOC and MINISANTE on strengthening of District Plans to Eliminate Malnutrition (DPEM) Collaboration with MINALOC and MINISANTE on monitoring DPEMs at 96 strategies and guidelines as appropriate Collaboration with MINISANTE and MINALOC and the NF&NTWG on monitoring NFNSP implementation In addition to promotion of full NFNP implementation assumption of principle responsibility for implementation of NFNP Strategy 3: “Promoting Household Food Security” /MINAGRI Nutrition Action Plan. Active collaboration and participation in the National 1st 1000 Days Campaign (Strategy 2) and assuring it is sustained Development of protocols for incorporating Household Food Security promotion with 1st 1000 Days CBF&NP activities. Incorporation of agriculture activities contributing to prevention of chronic malnutrition in children under two years into agriculture related training Collaboration with MINALOC on strengthen linkages of vulnerable households to food security , nutrition and social protection programmes Collaboration with MINALOC and MINISANTE and NF&NTWG on monitoring NFNSP Implementation district and lower levels. Facilitation of 1st 1000 Days CBF&NP activities through activities outlined in NFNP Strategy 3/MINAGRI Nutrition Action Plan. Integration of DPEM into District Development Plans (DDP) and budgets in collaboration with MINALOC and MINISANTE. Adapting protocols for incorporation of Household Food Security promotion with 1st 1000 Days CBF&NP activities. Expanded implementation of agricultural policy on land reform for improvement of household food security and income generation with priorities for staple foods such as rice, maize, potatoes. Reinforced nutrition surveillance system in collaboration with the MINISANTE, including mapping of food insecure zones. 97 Ministry of Defence (MINADEF) National Level Integration of food and nutrition activities in its Plans of Action Promotion of 1st 1000 Days to Prevent Stunting and related services and activities among military families. Logistical support, when possible for exceptional, large scale programmes. Ministry of Disaster Management and Refugees (MIDMAR) Primary responsible for Strategic Direction 6 in collaboration with MINISANTE Active collaborator on Strategic Direction 1, 7 National Level Improved nutritional diversity of food basket in emergency preparedness and response, especially addressing the special needs of pregnant women and lactating, children 6-24 months and other highly vulnerable persons. Enhanced emergency preparedness and response that include necessary linkages with MINISANTE to assure regular monitoring for acute malnutrition (sever and moderate), and necessary therapeutic and supplementary food products to assure effective case management Decentralize level Coordinate work to asses and determine the food and nutritional needs and status of current refugees and lead advocacy to correct any problems. Coordination preparations of plans for any future influx of refugees includes adequate preparations for nutritious foods and feeding for all persons affected including most vulnerable individuals and groups, Ministry of Education (MINEDUC) Primary responsible for Strategic Direction 5. Active collaborator on Strategic Direction 2, 3, 4 National level Leadership on implementation of NFNP Strategy 5: Improving Food and Nutrition In Schools” and the School Health Policy interventions Strengthened and expanded school food and Decentralized levels Implementation of Expanded Strengthened and expansion of growth monitoring for preschool and school children. Expanded integration of gardening 98 nutrition strategies, interventions and programmes Monitoring NFNSP Strategy 5 and the food and nutrition elements in the School Health Policy collaboration with MINAGRI, MINALOC, MINISANTE and the NF&NTWG Development of practical guidelines for incorporation of nutrition and household food security concepts and skills into education curriculum and extracurricular activities. Incorporation of the key concepts of the “1st 1000 Days window of opportunity in including key services for prevention of chronic malnutrition in children secondary school curriculum and animal husbandry with learning objectives related to household food security and family nutrition at all levels. Agreement on and introducing 1st 1000 Days concepts into curricular and extracurricular activities into schools and preschool activities. Expanded Integration of nutrition education in the community parental education program. Ministry of Gender and Family Promotion (MIGEPROF) Jointly responsible on Strategic Direction 2, Active contributor and collaborator on Strategic Directions 1, 2, 3, 4, 6, 7. National level Leadership advocacy for nutrition as woman and child right Effective advocacy for adequate (fully paid) maternity leave for breastfeeding working women. National promotion of 1st 1000 Days and related services and practices through radio and television Family Performance Contracts Special activity periods focused on nutrition and household food security Assure family and gender sensitivity in emergency preparedness and response Decentralized levels Collaboration with MINAGRI, MINALOC and MINISANTE on identification and support for food insecure families and households. Family Performance Contracts Special Activity periods focused on nutrition and Household Food Security NCW Village Committees Kitchen Cooking demonstrations with linkage to 1st 1000 Days F&NCBP 99 Ministry of Health (MINSANTE) NFNP co-owner Primary responsible for Strategic Direction 4. Jointly responsibility for Strategic Directions 1, 2, 7. Active collaborator on Strategic Direction 3, 4, and 5. National level Provision of leadership in NFNP implementation as co-owner of the multisector NFNP. Co-chair of F&N Steering Committee in Social Cluster Ministries Collaboration with MINALOC and MINAGRI and other Ministries and the NF&NTWG to elaborate national nutrition strategies and guidelines as appropriate Collaboration with MINAGRI, MINALOC and NF&NTWG on monitoring NFNSP Implementation Promotion of implementation of the full NFNP Principle responsibility for Strategy 4: on preventing and managing malnutrition interventions Active collaboration and participation in the National 1st 1000 Days Campaign (Strategy 2) and assuring it is sustained Strengthened in-service training Decentralized levels Serving as Co-chair of the District Food and Nutrition Steering Committee and ensure that each district completes District Plans to Eliminate Malnutrition Collaboration with MINALOC and MINAGRI on development and strengthening of District Plans to Eliminate Malnutrition (DPEM) Collaboration monitoring multisector DPEM implementation at decentralized level.Coordination by CHWs of 1st 1000 Days CBF&NP activities in cooperation with MINAGRI and MINALOC (and NGOs) as outlined in NFNP Strategy 2 and associated protocols and guidelines. Collaboration with MINALOC and MINISANTE to assure DPEM integration into District Development Plans and budgets Adaptation of relevant health and nutrition promotional materials and guidelines for use in supporting 1st 1000 Days CBF&NP activities. Expansion and effective use of Rapid-SMS to support nutrition surveillance in collaboration with the MINAGRI Collaboration with MINAGRI in mapping of food insecure zones. 100 on relevant health services and key practices to prevention of chronic malnutrition and link with agriculture related training Development protocols for adapting existing Community based Nutrition Programmes activities into the 1st 1000 Days CBF&NP activities. Coordination of national plan for capacity building in food and nutrition Reinforcement of the role of nutritionists at the central and local levels , Collaboration with MINAGRI and MINALOC and NF&NTWG on communication and advocacy strategies for food and nutrition. Definition of norms and standards of nutrition with other ministries and NF&NTWG Reinforcement of nutritional surveillance system (collaboration with MINAGRI, MINALOC Collaborating with MINALOC and MINAGRI and development partners in monitoring NFNSP Implementation Ministry of Justice (MINIJUST) Active collaborators on, NFNP Strategic Directions 1 National level Intervention in the approval and monitoring of food and nutrition related laws, codes and legislations. 101 Ministry of Infrastructure (MININFRA) Active collaborators on, NFNP Strategic Directions 4 (hygiene and sanitation) National level Improvement to infrastructure that facilitates marketing of fresh and processed foods. On-going improvement to safe water infrastructure and its equitable distribution and management. Develop and implement master plan for housing to reserve space for agricultural production. Expanded implementation of grouped housing policy (village) that saves land for agriculture. Promotion of collective environmental management activities. Decentralized levels Improvement in solid waste disposal, Enhanced collaboration with MINISANTE Department of Environmental Health on Community based Hygiene and Sanitation activities Ministry of Local Government (MINALOC) NFNP co-owner Jointly responsibility for Strategic Directions 1, 2, 7. Active collaborator on Strategic Direction 3, 4, 5, 6. National level Leadership in NFNP implementation as co-owner of the multisector policy. Serve as Co chair of F&N Steering Decentralized levels Serving as Chair of the of the District Food and Nutrition Steering Committee ensure completion of DPEM and their integration into District Development Plans Coordinating with MINISANTE, MINAGRI, MIGEPROF, and MINEDUC on development of DPEM. Assure protocols for social protection linkage with NFNP Strategic Direction 2 and 3 are appropriately adapted and followed. . 102 Committee in Social Cluster Ministries Collaborating with MINAGRI and MINISANTE and other Ministries and the NF&NTWG as appropriate to elaborate national nutrition strategies and guidelines. Collaborating with MINISANTE and MINAGRI and other Ministries and the NF&NTWG on implementation and monitoring of the NFNP. Actively collaborating and participating in National 1st 1000 Days Campaign and assure it is sustained With MINAGRI, MINISANTE, MIGEPROF, develop protocols of Coordinating monitoring of multisector DPEM Actively participating 1st 1000 Days CBF&NP activities. Ensuring children's protection through respect of their rights in regards to food and nutrition 103 social protection linkage with NFNP Strategic Directions 2, and 3 to guide districts. Leading Ministry for improving linkages between social protection programmes and food and nutrition (targeting with food and nutrition indicators that reinforce nutritional support to vulnerable groups. Collaboration with MINISANTE and MINAGRI and the NF&NTWG on monitoring NFNSP implementation The Ministry of Natural Resources (land, forests, environment and mining) (MINIRENA Active collaborators on, NFNP Strategic Directions 1, 2, 4, National level Adoption and implementation of the National Policy on Decentralized levels Tree planting and tree nurseries to protect ecosystems that favour agricultural production. Promotion of potable water, sanitation, hygiene education in schools and 104 Genetically Modified Organs. households. Promote the land protection to increase the food production/security Ministry of Public Works and Labour (MIFOTRA) Active collaborators on, NFNP Strategic Directions 1, 2, 3, 4 National level Increased duration and advantages for maternity leave totally paid for working women. Increased time-off allocated for breastfeeding for women after maternity leave. Support for establishment of breastfeeding women support groups in work places. Promotion of the linkage of healthy nutrition and increased productivity including the gained productivity based on reduction in child stunting (1st 1000 Days), prevention of iron deficiency anaemia and other food and nutrition related factors. The Ministry of Sport and Culture (MINISPOC) Active collaborators on, NFNP Strategic Directions 1,2,3,4,5, 6, National and decentralized levels Enhanced integration and support for nutrition in youth clubs, anti-AIDS clubs, sport clubs, etc. Promotion of healthy nutrition and diet as a traditional and cultural value. Ministry of Trade and Industry (MINICOM) Active collaborators on, NFNP Strategic Directions 1,2,3 National level Sustained monitoring of import regulations on iodized salt in collaboration with MINISANTE. Enforcement and monitoring of new standards for requirement that all staples, imported and nationally produced are appropriately fortified. (Wheat flour, oil, maize flour, etc.). Promotion and support for local production of fortified staples and highly nutritious supplementary foods for use in management of acute moderate malnutrition and, where necessary for highly vulnerable groups such as families affected by HIV and tuberculosis and to support PMTCT. Ministry of Youth and ICT (MYICT) Active collaborators on, NFNP Strategic Directions 1, 2, 3, 4, 5 National and decentralized levels Facilitation of the integration of healthy foods and nutrition and promotion of 1 st 1000 Days to 105 prevent stunting through channels that ready youth. Rwandan Bureau of Standard (RBS) Active collaborators on, NFNP Strategic Directions 1,3 National level Definition and dissemination of quality standards of imported or locally produced foods including micronutrient fortified products. Reinforcement of food quality control. Districts Decentralized implementer of NFNSP Strategic Directions 1,2,3,4,5,6,7, Set up District Food and Nutrition Steering Committee led by MINALOC with co-chairs from MINISANTE. MINALOC (social protection) MINAGRI and MIGEPROF. Review and 106 strengthen DPEMs with major additional emphasis on prevention of stunting in children under two years. Develop plan for DPEM implementation with emphasis on assisting communities to set up 1st 1000 Days CBF&NP. Develop collaboration protocols for multi sector collaboration in joint facilitation of 1st 1000 Days CBF&NP by frontline staff of MINALOC, MINAGRI, MINISANTE, and MIGEPROF. Develop DPEM and 1st 1000 Days CBF&NP multisector monitoring systems. Document lessons learned and share across sectors 107 and districts. Development Partners (national and international NGOs, Professional Associations, UN organizations, bilateral and multilateral donors) Active collaborators on, NFNP Strategic Directions 1, 2, 3, 4, 5, 6, National level Support and participation in sustained advocacy for nutrition Technical and financial support for the NFNP strategies, interventions, operational and supportive activities and services. Active participation in the NF&NTWG and support for its activities. Promotion of greater Decentralized Levels Technical and Financial support to district, sector and community based programmes. Development, production and dissemination of programme communication support materials. Documentation and sharing of operational issues and innovations across districts and nationally. Technical assistance and operational trials and adjustment of community and district level monitoring systems for food and nutrition strategies. 108 information sharing on interventions and operational issues relevant to improving implementation of NFNP strategies at all levels Private sector National level Increased investment in production, processing and marketing of high quality, safe and beneficial food products for local consumption and export. Increased support for implementation of NFNP interventions and activities. National and decentralized levels Support for and participation in the 1st 1000 Days national campaign including company programmes that motivate and promote services and practices to prevent stunting among staff. 109 Monitoring, Evaluation and Operational Research National level NFNSP monitoring Coordination of monitoring and evaluation at national level of NFNP implementation through the NFNSP 2013-2018 and annual JAPEMs will be organized by the SCF&NSC. Information on an agreed set quantitative and qualitative outcome indicators will be drawn mainly from established management information systems and monitoring procedures of the participating sectors and related management information systems, national surveys (RDHS, CFSVA\NS and FNSMS) (see Annex 1). Other monitoring information ould include international guidelines and operational research on innovations and interventions and sector review missions. Operational progress on DPEM planning and implementation through 1 st 1000 Days F&NCBPs will also be assessed mainly at district level but also through quarterly visits to districts and lower levels by multisector teams drawn mainly from the NF&NTWG. Macro analysis of information on nutrition and key health indicators obtained through the RapidSMS system nationwide will also be used. The NFNSP accepts that capacity building in monitoring and evaluation procedures and ranging from efficient data collection, analysis and effective reporting will be needed and that activities in this area will require expertise and technical assistance from different sources including national and provincial level specialists, NGOs and other development partners. A gap analysis of constraints on NFSP monitoring may be needed in order to develop an effective capacity building strategy in this area. This would-be carried out under Strategic Direction 7. District level NFNSP monitoring At District level NFNSP monitoring will be planned in the context of three year DPEM and one year action plans. Capacity building in the area of multi-sector programme monitoring at district level is needed. Guidance and training will be required from teams from the NF&NTWG including Development Partners. Orientation and training at district level will be done in the context of monitoring the DPEM. Sectors will provide information from their information systems and this information will be complemented by a 1 st 1000 Days CBF&NP progress reporting system organized by DF&NSC. This system will include a visual display of sector and joint sector output indicators that show progress toward the district’s annual objectives in terms of preventing stunting in children under two years of age. Supportive supervision will be used throughout the year to assist in improving the technical quality, coordination and sector personnel participation in sector specific and joint activities. Community level NFNSP monitoring Community based monitoring of food and nutrition also needs to be strengthened. This includes development of key indicators by and for the 1 st 1000 Days groups and their 110 community leaders. Successful outcomes in terms of better health and normal of children in every community, depends in part on full participation by those families and women who are preparing for and within the 1 st 1000 period. Community leaders, CHWs and others need to assist in assuring that the poorest and most vulnerable are encouraged to participate on a regular basis. RapidSMS, which allows for real time information including maternal health and nutrition indicators by CHWs and for data analysis at each level down to that of health facility may be further adapted to expand and strengthen monitoring of the 1 st 1000 Days CBF&N Programmes. The system holds major potential for tracking “1000 days women and families” and alerting CHWs to encourage their regular participation in CBF&NP activities. Operational Research Agenda The NFNSP 2013-2018 includes several innovative interventions, intervention packages and joint sector strategies. Many of these have been modelled at sector or district level and found to be effective on improving specific indicators. Over the next five years, substantial emphasis will be placed on scaling up interventions and strategies as broadly as possible in as many districts as possible. To remain effective, strategies will have to be adapted to different areas and different circumstance across the country. In addition, many of the intervention strategies included in the NFNSP will have substantially greater technical input and assistance as they are developed and promoted for broad expansion. These circumstances call for an on-going problem based agenda of operational research to be developed and an active system for documentation and information sharing of lessons learned. This will be particularly important at district and lower levels. This system should accommodate sharing both formal and less formal information from all levels and particularly districts. The system should focus on innovations that can be adapted and used and lessons learned from 1 st 1000 Days CBNP. Resource allocation and mobilisation Because the NFNSP 2013-2018 adopts a cross sector approach, the major portions of the overall plan depends on successful implementation by the Social Cluster Ministries and Development Partners of their nutrition-specific and nutrition-sensitive services, programmes and interventions, using sector allocated and mobilized resources. The strategic directions that include multi sector activities requiring collaboration among different Ministries and partners will also benefit from funds already allocated to related activities such those in the MINAGRI Nutrition Action Plan, MINISANTE HSSP III , MINEDUC School Health Policy and MINALOC social protection services. Advocacy will be required to assure current and planned activities of the NFNSP remain or become priorities with sufficient resources. These may be allocated from within the sectors or from Development Partners. Development Partners have already begun to “buy into” national efforts to “Scale up Nutrition” and more aggressively implement national scale efforts to prevent child stunting and solve other nutrition and household food security related problems. 111 Substantial assistance for initiating 1st 1000 Days Food CBF&NP in more than 10 districts and for many closely related activities at decentralized level was provided for up to five years beginning in 2013 from Development Partners including bi-lateral donors, the One UN and NGOs. These partners should be approached to assist with the operational research, modelling and other planning that is needed to support sector-specific interventions called for by the NFNSP. Participating Ministries and Development Partners are also viewed by the NFNSP as sources of technical assistance and for funds needed to conduct cross-sector operational research, food and nutrition advocacy, and activities related to planning, monitoring and completing annual JAPEM and new NFNSP in five year periods linked to the EDPRS cycles. At District level, integration of DPEM to District Development Plans and budgets is called for by NFNP based on the importance of the interventions to district development. By strengthening the DPEM, agreed activities should have budget lines. In addition, advocacy will be required to assure Ministries sustain, strengthen, expand and promote the actions called for in the NFNSP. While the NFNSP anticipates support for staff participation in joint activities from the relevant sector ministries, additional resources will be needed under Strategic Direction 2 to adjust community based food and nutrition activities toward the more multi-sector 1st 1000 Days CBF&NP models. Resources will also be required to facilitate planning activities and monitor progress. Resources for these activities will be drawn from Sectors and sought from Development Partners. Additional support will be required for overall NFNSP development and monitoring and to develop and prepare new communication support materials that support the 1st 1000 Days national campaign, orientation on the multi-sector integration of DPEM and their monitoring and to support activities not covered by specific sectors and outside the resource base of many communities. Sources of funds, technical assistance and supplies and commodities for such work will be worked out with the SCF&NSC. Funds will also be required for some interventions and support activities called for in the NFNP. These include, among others development of a comprehensive “National Capacity Building Plan in Food and Nutrition”, development of a “National Strategic Plan to Prevent Anaemia” and a consolidated “Problem Based Food and Nutrition Research Agenda”. Conclusion Despite the number and scope of the challenges remaining from the 2007 National Nutrition Policy that need to be addressed, the National Food and Nutrition Policy (2013) was developed in an environment of considerable past achievement Rwanda’s joining of the international Scale Up Nutrition–1st 1000 Days Movement in 2012 and its launching of the national campaign 1st 1000 Days in the Land of 1000 Hills during Umuganda in September 2013 generated new levels of commitment and brought help bring 112 new resources to nutrition programmes focused on reducing child stunting. Active Government and media participation along with international support has facilitated resources availability and enhanced commitment to National Food and Nutrition Policy programmes across sectors at central and decentralized levels.31 That campaign also benefitted nutrition and food program implementers through introducing to communities the importance of the critical 1000 day “window of opportunity” during which the permanent damage of child stunting can be prevented. (See Box 5) The campaign also brought strategic communication support to serve as a basis of support for 1 st 1000 Days community based programme services and practices, thereby increasing popular demand and participation. Renaming the NNP, the National Food and Nutrition Policy and expanding ownership and primary implementation responsibilities to include MINISANTE, MINALOC, and MINAGRI increased sector commitments and opened opportunities for joint programmes packages. These should allow more effective DPEM and their integration into the cores of District development planning, budgeting implementation and monitoring. During 2013 as the National Food and Nutrition Policy was under development, some agreements had been completed and others were under final negotiation with international partners that include an initial tranche of funding and technical support for national and district levels projects and programmes> many of these focus on linking household food security, activities to improve practices related to MYICN and social protection services. . These projects place a high priority on community based programmes to address child stunting and increase the opportunity for successful implementation of the National Food and Nutrition Policy. The agriculture sector’s enhanced commitment to strategies that systematically support household food security adds potential to the policy objective of rapidly reducing the percentage of households with problems of nutritious food access. These strategies can have tremendous impact if activities are targeted as planned to areas with the greatest problems and, where possible to the most vulnerable families and groups. Impact can be further increased if useful lessons learned are captured and adapted for improving household food security in homes at national scale. Plans to effectively link household food security improvement strategies and interventions with the most vulnerable families, offers an important pathway to effective social protection and the potential for better nutrition. Continuingly improving child health services at facility and community levels, greater access through health insurance expansion and improved household and community hygiene are helping to break the dangerous synergy of infection and malnutrition. Strong MINISANTE commitment helps assure such services will be sustained, expanded where national coverage has not yet been achieved, and strengthened where operational gaps are identified. 31 1st 1000 Days in the Land of 1000 Hills to Prevent Stunting campaign was launched during Umuganda (30 September 2013) with support and participation from the Prime Minister’s Office, each of the Social Cluster Ministries, UNICEF and national media. 113 Provision of food in schools remains severely limited and existing programmes do not reach high percentages of students despite universal agreement on the benefits of such activities. However, the completion of a plan for a “Home Grown School Feeding Programme” provides a framework to address this large nationally. The commitment of the education sector to strengthening food and nutrition through curricular and extracurricular activities provided an important opportunity to build knowledge and better prepare students to participate effectively in protecting their own and their future children’s nutrition. Active participation by many levels of Development Partners providing high levels of commitment and effective advocacy, essential funding for development and trial of innovative interventions and strategies, and added technical, increases the opportunity for NFNP implementation success. In such an environment of opportunities, there is substantial opportunity to meet many of the existing nutrition and household food security challenges that face the country. The new National Food and Nutrition Policy includes a strategic direction aimed toward effective advocacy to sustained and further build commitment to the Policy and its strategic priorities. This revised policy is not resource demanding because it mostly calls for adjusting, strengthening and expanding existing programmes, and continuous improvement through more effective monitoring and strategic adjustment in the context of the country’s adoption of performance based financing. The NFNP provides a conceptual framework, interrelated strategic directions, organizational and coordination mechanisms and plans for resource allocation and mobilization. Its collaborative implementation by all sectors of Government with continued support from Development Partners should lead to achievement of stated objectives and move the country toward the overall goal improving household food security and the nutritional status of the Rwandan people. In doing this chronic malnutrition in children under two years of age should be reduced along a trend line that intersects in 2018 with the objective set by the HSSP III (24.5%) and continues downward. Active identification and effective management of all cases of acute malnutrition will be sustained and further improved. 114 Main Background Documents Agricultural Policy and Institutional Framework for Transformation of Agriculture, Economic Development and Poverty Reduction in Rwanda. F. Malinda and Abbot, Kigali: Rwanda Institute of Policy Analysis and Research (April 2012) Business Plan 2006-2008. Kigali: Rwanda Agricultural Development Authority (RADA) MINAGRI Government of Rwanda (November 2005) Community-Based Environmental Health Promotion Programme: Improving Hygiene Behaviour of Communities throughout Rwanda, Environmental Health Desk, Ministry of Health (MINSANTE) Government of Rwanda (2012). Comprehensive Food Security and Vulnerability Analysis and Nutrition Survey 2012, Kigali: National Institute of Statistics of Rwanda, Ministry of Agriculture and Livestock Resources and World Food Programme, Government of Rwanda, (2012) Comprehensive implementation plan on maternal, infant and young child nutrition, .Committee A, third report, Geneva: Tenth plenary meeting, WHA65.6, Sixty-fifth World Health Assembly, (May 2012). Concept Note for the Rwanda’s “A Thousand Days in the Land of A Thousand Hills” (Nutrition Campaign), Kigali: Ministry of Health MINISANTE, Government of Rwanda (October 2012) draft Contextualising complementary feeding in a broader framework for stunting prevention, Christine P. Stewart, Lora Lannotti, Kathryn G. Dewey, Kim F. Michaelsen and Adelheid W. Onyango. Maternal and Child Nutrition (Suppl. 2) (2013.) Economic Development and Poverty Reduction Strategy 2013-2018-Kigali: Ministry of Finance and Economic Planning (MINCOFIN) Government of Rwanda (2013). Economic Development and Poverty Reduction Strategy [EDPRS], 2008-2012, Kigali: Ministry of Economic Cooperation and Finance MINECOFIN, Government of Rwanda (September 2007) Education Sector Strategic Plan 2010-2015. Kigali: Ministry of Education MINEDUC, Government of Rwanda (July 2010) Home-Grown School Feeding Programme, White Paper, and Kigali: Ministry of Education MINEDUC, Government of Rwanda, (2013). JAPEM Assessment Report. Kigali: Ministry of Health MINISANTE, Government of Rwanda (September 2012) draft Maternal and Child Nutrition 2, Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Zulfi qar A Bhutta, Jai K 115 Das, Arjumand Rizvi, Michelle F Gaffey, Neff Walker, Susan Horton, Patrick Webb, Anna Lartey, Robert E Black, The Lancet Nutrition Interventions Review Group, and the Maternal and Child Nutrition Study Group www.thelancet.com Published online June 6, 2013 http://dx.doi.org/10.1016/S0140-6736(13)60996-4 (June 2013) National Disaster Management Plan, Kigali: Ministry of Disaster Management and Refugee Affairs MIDMAR, Government of Rwanda (October 2012). National Joint Supervision on DPEM Implementation. Kigali: Ministry of Health MINISANTE, Government of Rwanda (June 2012) National multisector Strategy to Eliminate Malnutrition in Rwanda 2011 - 2013. Kigali: Ministry of Health MINISANTE, Government of Rwanda (May 2010). National Policy and Strategy for Water Supply and Sanitation Services, Kigali: Ministry of Infrastructure (MININFRA) Government of Rwanda (January 2010). National Social and Behaviour Change Communication Sub-Strategy for Maternal, New born and Child Health, Kigali: Ministry of Health MINISANTE Government of Rwanda (January 2012) Needs Assessment and Action Plan for Improving Agricultural Research and Technology Transfer. Izikara C., Wilcock D. and Habyarimana P.C Kigali: Government of Rwanda and the World Bank (2007) Nutrition Action Plan 2013-2018. Kigali: Ministry of Agriculture and Animal Resources MINAGRI (July 2013) draft Nutrition Stakeholder Mapping. Kigali: Ministry of Health, Government of Rwanda (2012) Policy for Agriculture and Horticulture in Rwanda, A different political economy? David Booth and Frederick Golooba-Mutebi Futures Agriculture (March 2012) Rwanda Social Protection: An Ongoing Process, Theophile Ruberangeyo, Crispus Ayebare, Astrid De Laminne De Bex, Volume 18: Successful Social Protection Floor Experiences, UNDP, (2011). Rwanda: Poverty Reduction Strategy Paper—Progress Report, Washington: IMF Country Report No. 11/154 (June 2011). School Health Policy, Kigali: Ministry of Education MINEDUC, Government of Rwanda (May 2013) draft Third Health Sector Strategic Plan, 2012-2018. Kigali: Ministry of Health MINISANTE, Government of Rwanda (2012). United Nations Convention on Rights of the Child (UNCRC) on (July 1990). http://dx.doi.org/10.1016/S0140-6736(13)60996-4 116 Vision 2020, Kigali: Ministry of Economic Cooperation and Finance MINECOFIN, Government of Rwanda (July 2000). 117 Persons consulted and/or participating in workshops for the development of the National Nutrition Policy and National Nutrition Strategic Plan 2013-2018 Ahoranayezu, J. Bosco. Consultant Public Health Specialist * Bahimbayandi, Gedeon. MIGEPROF. Family Promotion Bankundiye, Etienne. Nyamasheke. District. Director of Health Barigira, J. P. Burera. District Statistician Bayisabe, Salomon. Musanze District. Director of Planning Bienvenu, Leon. FHI 360. Technical Officer Nutrition Bihibindi, Vianney. Partners in Health. Nutrition Coordinator Bizimana, Eric Muhanga. District Director of Planning (Monitoring and Evaluation) Bucumi, Jean Claude. FEWS Net. Technical Assistant Buranga, Umulisa Assoumpta. Huye District. Monitoring and Evaluation Byinshi, Francois. Nyagatare District. Direct of Planning (Monitoring and Evaluation) Byukusenge, Claude.Kierehe District. Director of Planning (Monitoring and Evaluation) Chizelema, Dan. FEWS NET. County Representative Corney, Julie. Gardens for Health. Country Director Delaney, Hugh. UNICEF Rwanda Country Office. Education Specialist Delbaere, Jan. WFP. Deputy Country Director Deputy Director General, Dusenge, Pierro. Nyabihu District. District Health Officer Dusingizimana, Theogene. KIST. Assistant lecturer Froling, Maarten, Netherlands Embassy. Food Security/Social protection Gafurumba, Felix. Kamonyi District. District Health Officer Gasana, Celestin. Musanze District. District Health --Officer Gatsinzi, Justine. Rwanda Local Development Support Fund, Social Protection Program Gegout, Chantal. WHO. Nutrition/WCD Officer Gleason, Gary, International Nutrition Foundation, Consultant Policy Specialist* Habimana, Jacques. MINEDUC: School Health and Nutrition. Habiyambere, Emmanuel. Rusizi District. Director of Planning (Monitoring and Evaluation) Formatted: French (France) 118 Habyarimana, Jean Baptiste. MINAGRI. Agricultural Statistician Haguma, Pascal. Rubavu. District Director of Planning (Monitoring and Evaluation) Hakizimana, Patrice. USAID. Agriculture. Specialist Hassinen-Agoya, Mari. WFP. Head of Programme Hitimana, Régis. MINISANTE. Planning & HIS Department, Ilibagiza, Denise, UNICEF Rwanda Country Office, Health Officer Kabano, Charles. Ruhango District. Direct of Planning (Monitoring and Evaluation) Kalisi Vanessa, Clinton Health Access Imitative (CHAI), Nutrition Program Kampirwa, Rachel. Rwanda Family Health (RFHP). Nutrition Specialist Kankindi, Marguerite. Nyanza District. District Health Officer Kanyaandekwe, Eugene. Bureau de regional Cooperation Swiss Grand Lakes. NPO Agriculture and Food Security Kanyandekwe, Eugene. SDC Programme Officer Kanyeganza, Emmanuel. Ngororero. District Director of Health Karambiz, François. Bugesera District. Director of Health Karumba, Silver. USAID. Nutrition Specialist Kayiranga, Didace. World Food Programme. Rwanda National Program Officer Kayiranga, Paul. Rwamagana District. Director of Planning (Monitoring and Evaluation) Kayiranga. J. Damascene. Kirehe District. Health Director Kayirangwa, Jeannette. ONE UN. National Facilitator* Kayitesi, Colette. Nyamagabe District. Health Director Kayumba, Emmanuel. Gicumbi District. Health Director Kayumba, Josephine. UNICEF Rwanda Country Office. Nutritionist* Kazungu, Leopold. MINISANTE, Community Based Nutrition Programme (CBNP) Officer Kubach, Tarik. European Union Delegation to Rwanda. Rural Development Attaché Lonc, Tomaz. FAO. Alternate Representative Machara, Faustin. Rwanda Biomedical Centre (RBC). Nutrition/HIV Specialist Manirafasha, Jean D’Amour. Rulindo District. Director of Health Manirareba, Jeanne d'Arc. Caritas Rwanda. Nutrition Officer Mantilla, Franklina. ONE UN. International Facilitator Manzi, Emmanuel, UNICEF Rwanda Country Office Health Specialist Micomyiza, Evode. MCHIP/PATH. Nutrition Program Manager Mitraros, Audri Vlinton. Clinton Health Access Initiative (CHAI) Analyst. Mucumbitsi, Alexis. MINISANTE MCH Department. In charge of Nutrition* Mugabo, Faustin. Bugesera District., Director of Planning (Monitoring and Evaluation) Mugiraneza Thierry. Kayonza District. Director of Planning Mugume, Nathan. MINISANTE, Rwanda Health Communication Centre. Director Muhinda, Otto Vianney. MINAGRI. Food Security and Nutrition Coordinator Mujawamariya, Mediatrice, Huye District. Supervisor, Nutrition Mukabutera, Assumpta. NURSPH. MPH and PHD Programme Coordinator. Mukagahima, Claudine, MINEDUC. Environmental Hygiene and Nutrition Mukamana, Alphonsine. Nyamagabe District. Statistician Mukamana, Amiel Clemence. Rutsiro District. District Health Officer Mukamaseri, Evelyne. Kicukiro District. Monitoring and Evaluation Mukandakebuka, Justine. MINALOC, Social Protection/Nutrition Mukantaganzwa, Brigitte. Nyanza District. Director of Planning (Monitoring and Evaluation) Mukase, Valentine. Karongi District. Director of Planning (Monitoring and Evaluation) Munyandekwe, J. Nepo. Nyamasheke District. Director of Planning Muratwa, Ignacianna. Ruhango District. Health Activities Supervisor Muriisa, Grace. UNICEF Rwanda Country Office, HIV Specialist Formatted: Italian (Italy) Formatted: English (U.S.) Formatted: Italian (Italy) Formatted: French (France) Formatted: Italian (Italy) 119 Musaninkindi, Nadia. FEWS Net. Technical Assistant Mushabe, Richard. Ministry of Finance and Development Planning. Social Sector Policies and Programs Expert. Musoni, J. de Dieu. Kicukiro District. Director of Planning (Monitoring and Evaluation) Mwanyumba, Fabian. UNICEF Rwanda Country Office. Chief HIV and AIDS Nayigiziki, Eulade. Ngororero District, Director of Planning Ndamuzeye, Emmanuel. Rusizi District. Director of Health Ndangamiyumikiza, Samuel. Concern Rwanda. Health and C.B manager Ndayisaba, Jonas. Rwamagana District. Monitoring and Evaluation Officer Ndayisaba, Steven. Ngoma District. Director of Planning (Monitoring and Evaluation) Ndimurwaho J. Bosco, Gisagara District. Director of Planning (Monitoring and Evaluation) Ndizigiye, Carine. MINISANTE, Intern/CBNP Ngabo, Fidele. MINISANTE. MCH Director Ngamije, Joseph. CARE. C.S Manager Ngarambe, Alphonse. Kayonza District. Health Director Nwaigwe, Friday, UNICEF Rwanda Country Office, Chief Child Survival and Development, Bgiruwonsanga, Narcisse. World Relief. Nutrition Officer Nizeyimana, Abdou. Kamonyi District. Director of Health Nkunda, Evariste. Nyarugenge District. Director of Health Nkuru, Pascal. CONCERN. Nutrition Manager Nsabimana, Desire. Nyarugenge District. Director of Planning (Monitoring and Evaluation) Nsenga, Jean Pierre. SFH/RWANDA. MCH/Manager Nshimiyimana, A.Karim. Rulindo District. Director of Planning (Monitoring and Evaluation) Ntwari, Baziyaremye Nathan. MINMAR. Director of Strategic Planning Nyirajyambere, Jeanne. D'Arc CHF. Nutrition Advisor Nyiransabimana, Lydivine. MINISANTE MCH. Intern Nyiranyamibwa, Allen. Gasabo District. District Health Officer Nzibaliza, Naphtal. Gisagara District. District Health Officer Omwega, Abiud .UNICEF Rwanda Country Office. Nutrition Specialist* Rubibi Bitata, J. Christophe. Kamonyi District. District Hospital Monitoring and Evaluation Rutaganda, Jean Vianne. UNICEF Rwanda Country Office. WASH Specialist Rutikanga, Alex. Nyagatare District. Director of Health Rwahama, Jean Claude. MIDMAR. Director of Refugee Affairs Simpenzwe, Thomas. Gasabo District. Director of Planning (Monitoring and Evaluation) Tabaro, Rene KFH. Nutritionist Tekle, Ahadu. FAO. Intern Teteli, Cecile. CRS. Nutrition Team Leader Tumushine, Francine. MINALOC. Director General, Community Development & Social Welfare Department. Twizeyimana, J.Bosco. Gatsibo District. District Health Officer Ugabinema, Nicaise. World Vision. Monitoring and Evaluation Coordinator Umulisa, Brigitte. Rubavu District. Director of Health Umutiniwase, Kamana Sostin. Muhanga District. District Health Officer Umutoni, Carmen. WRR. Program Manager Uramutse, Gilbert. MIDMAR. Planning and Budgeting Officer Uwamahoro, Angelique. Ngoma District. District Health Officer Uwamahoro, Janviere. Gakenke District. Health Director Uwamahoro, Triphanie. Gakenke District. JADF PS Uwera, Denise. World Food Programme. FP SPA/Nutrition & HIV/AIDS Uwera, Kamanzi Odette. CRS. Senior Nutrition officer Uwimana, Muhire Marie Claire. WRR. Nutrition Officer Formatted: English (U.S.) Formatted: Italian (Italy) Formatted: Italian (Italy) Formatted: English (U.S.) Formatted: English (U.S.) Formatted: English (U.K.) Formatted: Italian (Italy) Formatted: English (U.K.) 120 Uwiringiyimana, Vestine. Kigali Institute of Science and Technology. Assistant Lecturer Uwizeyimana, Emmanuel. Nyabihu District. Director of Planning (Monitoring and Evaluation) Van Damme, Esther. Netherlands Embassy. First Secretary van Dorp, Marianne. Wageningen U R. Food & Nutrition Security Vasanthakaalam, Hilda. Kigali Institute of Science and Technology (CST). Head of Department Food Science and Technology Wittcoff Alison IRC Health coordinator Zurdo, Diego. European Union Delegation to Rwanda, Head of Section 2 Annex 1: Monitoring and Evaluation Framework Indicator Source of Data Freque ncy Measurem ent Level Responsibl e Entities Baseli ne (2010) Targets (M&E) FY: July-June 13 14 14 15 15 16 16 17 17 18 1. % of low birth weight HFS 3-5 years National MINISAN TE 2.8% 32 2. % of underweight children below five years of age RDHS 3-5 years National MINISAN TE 11% 8% 4 % 3. % of stunted children below five years of age RDHS 3-5 years National MINISAN TE 44% 24. 5% 18 % 4. Proportion of wasted children below five years of age RDHS 3-5 years National MINISAN TE 3% 2% 2 % 5. Proportion of overweight children below five years of age RDHS 3-5 years National MINISAN TE 7% 6. Proportion of thin school-age children and adolescents (5-19) years) School Survey 3-5 years National MINEDUC 7. Proportion of overweight school-age children and adolescents (5-19 years) School Survey 3-5 years National MINISAN TE 8. Proportion of school age children (5-10 years) with anaemia School Survey Annual National MINISAN TE 9. Proportion of school age children (5-10 years) with Vitamin A deficiency School Survey Annual National MINISAN TE 10. Proportion of pregnant women with anaemia RDHS Annual National MINISAN TE 17% 11. Proportion of pregnant women with malnutrition (BMI less than 18.5) RDHS 3-5 years National MINISAN TE 7% 32 HMIS report 2010-2011 (2.8% in health centres; 7.9% in district hospitals and 15.7% in referral hospitals 3 Proposed outcomes and outputs indicators Proposed Indicator Source of Data Frequency Measurement Level Responsible Entities Baseline Targets (M&E) FY: July June 13-14 14-15 15-16 16-17 17 18 Strategic Direction 1: Food and nutrition advocacy to sustain commitment and mobilize resources for policy implementation Outcome Indicators 1. # of districts that have integrated nutrition activities in their development district plans Activity report annually National SCF&NSC 2. # Number of new partners supporting nutrition activities Activity report annually National SCF&NSC 3. % in increased human resource for nutrition at all levels Activity report annually National SCF&NSC 4. # of leaders (disaggregated by sex, category and level of responsibility) who publically support the 1st 1000 days Activity report annually National SCF&NSC 5. % of activities implemented versus planned at national and district level Activity report annually National SCF&NSC Outputs indicators 6. # and quality of advocacy materials developed Activity report annually National SCF&NSC 7. # of senior government authorities involved in the advocacy and resource mobilization campaign Activity report annually National SCF&NSC 4 8. # of people (disaggregated by sex, profession, occupation ) reached versus targeted during the dissemination meetings Activity report annually National SCF&NSC 9. # of people reached versus targeted by the resource mobilization meetings Activity report annually National SCF&NSC Strategic Direction 2: Prevention of chronic malnutrition Outcome Indicators Proposed Indicators Source of Data Frequency Measurement Level Responsible Entities Baseline Targets (M&E) FY: July-June 13 14 14-15 15-16 16-17 17 18 10. % of children exclusively breastfed for 6 months RDHS 3-5 years National MINISANTE 85% 11. % of children age 0 23 who received post-natal visit from an appropriate trained health worker within three days after the birth of the youngest child RDHS 3-5 years National MINISANTE 18% 12. % of children aged 20-23 months still breastfeeding RDHS 3-5 years National MINISANTE 83.5% 13. % of children aged 6-23 months who received 4 or more feedings in the last RDHS 3-5 years National MINISANTE 25% 5 24 hours 14. % of children 6–23 months who receive minimum acceptable diet (apart from breast milk). RDHS 3-5 years National MINISANTE 17% 15. % of infants 6–8 months who receive recommended variety of food minimum number of times RDHS 3-5 years National MINISANTE 9% 16. % of women adopting special diet (frequency, quantity quality) during pregnancy & lactation. RDHS 3-5 years National MINISANTE 17. % of pregnant women receiving Fe+FA and taking them > 90 days RDHS 3-5 years National MINISANTE 1% 18. % of children under 5 years of age who received Vit. A supplements in the 6 months preceding the survey RDHS 3-5 years National MINISANTE 93% 19. % of households having access to iodized salt RDHS 3-5 years National MINISANTE 99% 20. % of children 6–23 months of age receiving iron fortified food designed for infants and young children, or receive food fortified in-home (MNP) RDHS 3-5 years National MINISANTE 20% 6 21. Proportion of children with severe acute malnutrition having access to appropriate treatment including therapeutic foods HFS33 Annual National MINISANTE 22. % of women receiving vitamin A supplementation in post-partum visits RDHS 3-5 years National MINISANTE 52% 23. Proportion of population with sustainable access to sanitation RDHS 3-5 years National MINISANTE 55% Output Indicators 24. % of Ministries which have involved their staff in the 1st 1000 days program. 25. Number of co branded interventions among ministries/ partners. 26. % of district F&N steering committees effectively involved in the implementation of the 1st 1000 Days 7 Strategic Direction 3: improving household food security (adapted from MINAGRI NAP) Outcome Indicators (CFSVA/NS34) Proposed Indicators Sourc e of Data Frequenc y Measuremen t Level Responsible Entities Baseline Targets (M&E) FY: July June 13 14 14 15 15 16 16 17 17 18 27. % of households with an unacceptabl e food consumptio n score CFSV 3 years National MOA 21% 40% 57% 72% 85% 70% +10 % 90% +10 % 70% 28. % of agricultural households practicing intercroppi ng with annual crops and fruit tree CFSV 3 years National MOA No baseline 20% 40% 60% 29. % of households in Ubudehe categories I, II, III with at least 3 chicken ( egg production) At least 3 rabbits CFSV 3 years National MOA No baseline +10 % +10 % +10 % 30. % of pre primary-, primary-, secondary and VTC CFSV 3 years National MINEDUC 41% 50% 60% 80% 34 CFSVA/NS: Comprehensive Food Security and Vulnerability Analysis and Nutrition Survey 8 schools with a school garden that demonstrat es food diversity, nutritious food groups and nutrition needs 31. % of agricultural households in Ubudehe Cat. I, II, III that own equipment for home based storage and processing of food CFSV 3 years National MOA/District s No baseline +10 % +10 % +10 % 32. % of health centres integrating agriculture outreach CFSV 3 years National MINISANTE baseline 10% 30% 50% 33. % of nursery and primary schools with regular provision of school feeding CFSV 3 years National MOA 7District s schools) Output Indicators 34. Number° of communicatio n tools on production CFSV 3 years National MOA No baseline 70% 9 and consumption of nutritious food disseminated 35. % of health sectors with a copy of a Kinyarwanda book of nutritious recipes CFSV 3 years National MOA No baseline 10% 30% 50% 36. % of households in Ubudehe Cat. I, II, and III receiving communicatio n tools CFSV 3 years National MOA No baseline 37. # of adequate recipes and guidelines on food utilization, storage, processing developed and disseminated CFSV 3 years National MOA No baseline Strategic Direction 4: Prevention and management of all forms of malnutrition Proposed Indicators Source of Data Freque ncy Measur ement Level Respon sible Entities Baseli ne Targets (M&E) FY: July June Outcome Indicators 13-14 14 15 15 16 16 17 17 18 10 38. % of mothers of children 0-23 months who live in a household with soap or a locally appropriate cleanser at the place for hand washing that and who washed their hands with soap at least 2 of the appropriate times during the day or night before the interview RDHS 3-5 years National MINIS ANTE 10% 39. % of children 0-23 months with diarrhoea in the last two weeks who were offered more fluids during the illness RDHS 3-5 years National MINIS ANTE 23% 40. % of children 0-23 months with diarrhoea in the last two weeks who were offered the same amount or more food during the illness RDHS 3-5 years National MINIS ANTE 4% 41. % of sick children in the past two weeks who continued breastfeeding and feeding foods other than breast milk 11 42. % of households consuming Vitamin A-rich vegetables/ fruits 43. % of people who report physical inactivity 44. % of people who report access to information and/or education campaigns promoting healthy eating 45. Existence of measures affecting food prices such as taxes on unhealthy foods and/or incentives on fruits/vegetables 46. Existence of initiatives to increase availability of processed foods with reduced content of total fat and/or added sugar 47. Existence of initiatives to reduce salt in processed food 12 48. % of HIV care and treatment sites providing individual nutrition counselling services 49. % of PLHA who know the three primary recommended ways to increase energy intake 50. % of children 6–23 months of age who receive iron-rich food or iron fortified food that is specially designed for infants and young children, or that is fortified in the home RDHS 3-5 years National MOH 20% 51. % of households consuming adequately iodized salt RDHS 3-5 years National MOH 99% 52. % of households with nutritionally vulnerable children, pregnant and lactating women in ubudehe 1 and 2 who receive high quality fortified food supplements Output Indicators 13 53. # of health providers trained on nutrition : prevention, detection and manageme nt of all forms of malnutritio n 54. # of CHWs who can correctly assess and classify an under-five child for malnutritio n 55. # of nutrition guidelines, posters, pamphlets and job aids produced and distributed 14 56. % of health centres with adequate required nutrition, commoditi es materials and equipment 57. # of radio spots aired on prevention malnutritio n of malnutritio n 58. % of households of children age 0-23 months that treat water effectively. RDH S 3-5 years National MINISANTE 49% Strategic Direction 5: Improving feeding and food and nutrition learning in schools Outcome Indicators Proposed Indicators Source of Data Frequen cy Measure ment Level Respo nsible Entiti es Baseli ne Targets (M&E) FY: July June 13-14 14 15 15 16 16 17 17 18 59. % of schools providING soap for hand washing (i.e. where enough soap is School survey 2 years National 15 available for students to wash their hands more than 80% of the time, or 4 out of 5 days per week. 60. % of school children who have regularly benefited from the “One Cup of Milk per Child” program 61. % of school children who have regularly benefited from the “Secondary School Feeding Program 62. % of school children who received the deworming drug 63. % of students (by sex) supplemented with Vita A Output Indicators 64. # of teachers trained on nutrition 65. Percentage of schools participating in the (deworming) program School monitor Annually National 66. % of schools providing micronutrient supplementat ion in the past year. 16 67. % of schools implementin g the “One Cup of Milk per Child” program 68. % of schools implementin g the “Secondary School Feeding Program Source of Data Freque ncy Measure ment Level Respons ible Entities Baseli ne Targets (M&E) FY: July-June 13 14 14-15 15 16 16 17 17 18 % of the population in emergencies situations who are informed about food hygiene % of households in emergencies that have access to cooking utensils, fuel, cooking water and soap % of targeted beneficiaries reached by food aid % of beneficiaries informed in advance of the quality and quantity of the food ration and the distribution plan % of the targeted population covered by supplementary and therapeutic feeding programmes (>50% in rural areas, >70% in urban areas and >90% in camps) 17 % of the targeted population which is within a one-day walk of the distribution site for supplementary food % of exist from supplementary feeding who recover (>75%) % of exist from supplementary feeding who default (<15%) % of exist from supplementary feeding who die (<3%) % of exist from therapeutic feeding who recover (>75%) % of exist from therapeutic feeding who die (<10%) % of exist from therapeutic feeding who default (<15%) # of targeted people who possess a copy of the contingency plan that addresses nutrition issues Proportion of health centres experiencing no stock-outs of essential nutrition commodities during emergencies situations # of reports to monitor the performance and adequacy of the food aid program 18 Strategic Direction 7: Supporting programmes and services Outcome Indicators Proposed Indicator Sourc e of Data Frequ ency Measu remen t Level Resp onsib le Entiti es Baseli ne Targets (M&E) FY: July-June 13 14 14 15 15 16 16 17 17 18 69. % districts who reported correctly and in timely manner on cases of malnutrition 70. % of HC that reported no stock out of Vita A, Fe and Folic Acid, therapeutic food 71. # of people aware of the consequences of stunting 72. % of under five children screened for malnutrition by CHWS 73. % of targeted health providers trained in nutrition 74. % of best practices/lessons learned from Rwanda Nutrition experiences shared nationally and internationally 75. % of districts that have developed and shared best practices in nutrition Output Indicators 76. # of coordination meetings organized 19 versus planned 77. # of supervisory visits at each level 78. # of nutrition progressive reports 79. # of meetings organized to raise awareness on nutrition 80. - % of districts that have updated plans including nutrition activities 20 Annex 2: Summary Estimated Budget for the National Food and Nutrition Strategic Plan (by Strategic Direction) Strategic Direction 1 RwF 126,916,694 Strategic Direction 2 RwF 4,956,063,980 Strategic Direction 3 TBD35 Strategic Direction 4 RwF 22,174,808,025 Strategic Direction 5 RwF 78,719,248,314 Strategic Direction 6 RwF 288,676,817 Strategic Direction 7 RwF 5,025,464,620 Total RwF 111,291,178,449 Notes on the Costing and Budgets for the Strategic Directions of the National Food and Nutrition Strategic Plan (2103-2018) 1. The costing of the NFNSP is based on fiscal years running 1—July – 30 June which is aligned with the financial schedules used by the Rwandan Government). 2. The NFNSP 2013-2018 budget covers five years An annual adjustment factor of +2.07% is used throughout the budget based on guidance from MTEF Guidelines of MINICOFIN. 3. This budget was done using “unit costing “as recommended in the National Planning, Budgeting and Medium Term Expenditure Framework (MTEF) Guidelines. 4. The NFNSP follows the National Food and Nutrition Policy which includes seven Strategic Direction each of which is a set of planned outputs to be achieved by carrying out outlined activities. 5. Working through each Strategic Direction and each output, individual activities were costed based on unit costs, quantifiable inputs and timeframes. Total activity costs are calculated by multiplying individual input costs by input quantities within and annual timeframe. Where appropriate, basic gap analyses were worked out to estimate costing of the real needs (inputs/quantities). 6. A total of some 153 activities have been costed. However, this number will change as annual operational plans are developed, required resources are allocated or mobilized, and activities are implemented, monitored and evaluated. 35 To be based on costing of the MINAGRI NAP 21 7. The costs for each activity of the seven seven Strategic Directions of the NFNP were estimated for each of the five years in the NFNSP (2013-2018) and then aggregated to develop the estimates cost of the achieving the outputs of each Strategic Direction. 8. The timing of many interventions activities and quantities per year are estimates. These are generally based on discussions of programme and activity schedules with appropriate stakeholders and technical specialists. Detailed annual planners and budget specialists need to closely monitor the following and revise annual budgets accordingly: 1. Actual vs. planned starting dates of new interventions and intervention packages (programmes) 2. Actual vs. planned costs per year based on progress and constraints related to the pace by which interventions move from modeling scale to national scale. 3. Changes in the MINICOFIN MTEF annual increase factor of (2.07%) for interventions 9. Because the NFNSP budget is multisector, many of the activities called for are also found in the strategic plans of participating Ministries’ and are funded through those Ministries or various Development Partners. To avoid confusion the logical frameworks of each Strategic Direction of the NFNSP includes a “Cross reference” (CR) column that note known organizations responsible for specific activities and the funds available for these activities. 10. In addition, to cross referencing between the NFNSP budget and other Government budgets, some activities were viewed as overlapping either within the same Strategic Direction or between two different strategic directions. When it was the case, only one activity was costed and cross-referenced for the second activity to avoid duplication 11. The costing exercise avoided estimating “lump sums.” In developing the costing the following questions were asked: 1. What do we need to implement? 2. Who will be involved in the implementation of the activity? 3. What resources are required for the implementation? 4. What are the required quantities and how often (frequency)? 5. What is the appropriate timing and when is the deadline? 6. The budget was developed using there linked Excel sheets: 1. Unit costs, 2. Detailed calculations taking into account key accurate assumptions for effective implementation of the targeted activity; 3. The overall whole activity plan where amounts listed are linked to the total amounts in the “assumptions” sheet. 22 7. For Strategic Direction 5 regarding food and nutrition in schools, we have used figure amounts given in the national School Health Strategic Plan. 8. For Strategic Direction 6 related to food and nutrition in emergencies, we have consulted experts in WFP. 9. Strategic Direction 3 which deals primarily with the MINAGRI Nutrition Action Plan, many areas has not been costed by this team because the NAP is being costed separately. When this activity is completed it will be possible to add in the figures provided, cross reference them and have a fully costed NFNSP.