Somali Nutrition Strategy 2011-2013

SOMALI NUTRITION STRATEGY 2011 – 2013 Towards the Millennium Development Goals ii © World Health Organization/UNICEF/WFP/FAO/FSNAU 2010 All rights reserved. The designation employed and the presentation of the material in this report including tables and maps, do not imply the expression of any opinion whatsoever on the part of the World Health Organization, UNICEF, WFP and FAO/FSNAU concerning the legal status of any country, territory, city or area or of authorities or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent border lines for which there may not yet be full agreement. imply that they are endorsed or recommended by the World Health Organization, UNICEF, WFP or FAO/FSNAU in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization, UNICEF, WFP and FAO/FSNAU do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. This publication may be reproduced free of charge in any format or medium, provided that it is reproduced accurately, that the original contributors are given due credit, and that it is not used in a misleading context. iii Foreword Good nutrition is one of the key foundations for the development of a healthy, productive population. Well nourished people are less likely to become ill or die, and are more productive and better able to learn. Achieving good nutrition, particularly among women and children, is associated with Situational analysis of data from Somalia over the last decade indicates that undernutrition is a on hunger, child health, maternal mortality, gender equality and education. Rates of acute and chronic malnutrition have remained persistently high throughout Somaliland, Puntland and South Central Somalia, with some variation by zone and livelihood system. nutritional status. However, there is a growing body of evidence that other underlying causes poor dietary diversity, inadequate infant, young child and maternal feeding practices, poor hygiene practices, water and sanitation, poor health seeking behaviours and low access to quality health services and education and gender inequalities. The persistence of undernutrition, even in years of relative stability and good harvest, adds further weight to the importance of these multiple underlying causes which by their nature cut across traditional sectors. With increasing understanding of the causes and their complexity, the challenge now is to strengthen efforts to address them through an integrated multi-agency, multi-sector response. status of the Somali population, thereby contributing to an overall improvement in their survival, growth and development. The activities detailed in this strategy aim to respond to the challenges raised above and focus i) improved provision of quality services for the management of acute malnutrition; ii) sustained quality nutritional surveillance and analysis of nutrition information to inform appropriate and rapid responses; iii) improved knowledge, attitudes and practices regarding infant, young child and maternal nutrition; iv) improved availability, accessibility and coverage of micronutrients and de-worming; v) increased redress of underlying negative practices through awareness and in country to make effective nutrition responses. The development of the strategy has been based on a number of guiding principles. Primarily the strategy recognises the basic human right to adequate food and health and freedom from implementation should not exacerbate or worsen the situation. accepted best practice and evidence-based programming. However, not all interventions proven iv feasible in the Somali context where the volatile environment, low access, weak infrastructure adapt what is proven effective, with what is viable in the context. focuses on investing in the areas most likely to achieve maximum impact. As such, interventions are targeted at pregnant mothers and children up to the age of two years as the critical window correspond to those acknowledged by the Copenhagen Consensus 2008 as the most cost effective interventions for global development. This strategy has been developed through strong interagency collaboration, with input and endorsement from Somali authorities. It is hoped the strength of this collaboration prevails throughout the implementation phase, in pursuit of a common overall goal to improve the growth, survival and development of the Somali people. The strategy provides the way forward for stronger partnerships within the nutrition sector and between nutrition and other sectors and ministries for coherent action to achieve this shared goal through improving the nutritional status of the population. UN Resident and Humanitarian Coordinator for Somalia v vi This Somali Nutrition Strategy has been developed in response to increasing evidence and awareness that the persistently high rates of malnutrition in Somalia are related to multiple underlying causes that need to be addressed through a more holistic and longer term approach. The process of developing the strategy has been a consultative. Initially, a task force of technical representatives from key UN agencies and local and international NGOs was formed to work on a draft. A results based, action orientated approach was adopted, using the logical framework to strengths, weakness, opportunities and threats of current nutrition programming. The draft prepared by the technical interagency task force was then shared with nutrition and other relevant clusters and sector working groups, and the UN County Team at Nairobi level. A key stage of the process was sharing the draft with Somaliland, Puntland and TFG authorities and consensus on the combined inputs of all relevant stakeholders. Preface vii Acknowledgements As outlined above, the process of developing this strategy has been a collaborative one between UN agencies, local and international NGOs, line ministries of Somaliland, Puntland and TFG authorities. We would like to acknowledge the contributions of staff from all these various agencies. In particular, special thanks go to members of the technical Task Force for their experience, knowledge Dr Anthony Abura World Vision International Anne-Sophie Porche Nutrition Cluster Coordinator, UNICEF SSC Unni Silkoset Nutrition Specialist, UNICEF Somalia CSZ Austen Davis Chief, Accelerated Child Survival and Development Programme, UNICEF Somalia Peter Hailey Regional Nutrition Specialist, UNICEF EASRO Randhir Singh Relief International Somaliland contributors Abdirahman Deria AGAAD Abdi Dahir Elmi WHO Ahmed Hassan ANPPCAN viii Theresa Loro WFP Asia Osman WHO Puntland contributors Abdikarim Husen Duale FSNAU Layla Said LQC TFG contributors Humanitarian Affairs Other contributors preliminary work on developing the strategy force and compiled the strategy document. Thanks also go to FSNAU/FAO for their assistance in the design of the document and to WFP who contributed to the funding of the process, including the consultancy costs. ix Acronyms CAP Consolidated Appeal Process CHD Child Health Day CTC Community-based Therapeutic Care EPHS Essential Package of Health Services FAO Food and Agriculture Organisation FEWSNET Famine Early Warning Systems Network FSNAU Food Security and Analysis Unit – Somalia GAVI Global Alliance for Vaccines and Immunisation HAZ Height for Age Z-score HSS Health System Strengthening IDP Internally Displaced Population INGO International Non Governmental Organisation LNGO Local Non Governmental Organisation NEZ North East Zone NGO Non Governmental Organisation NWZ North West Zone OTP Out patient Therapeutic feeding Programme RDP Reconstruction and Development Plan SC Stabilisation Centre SFP Supplementary Feeding Programme SCZ South Central Zone UNTP United Nations Transition Plan WASH Water and Sanitation Hygiene WFP World Food Programme WHO World Health Organisation WHZ Weight for Height Z-Score x Table of Contents Foreword iii Preface vi Acknowledgements vii Acronyms ix Executive Summary 1 1.2 Determinants of malnutrition 4 2.2 Scope 8 4.2 Partnerships 14 4.4 Formative research 16 Annexes Annex 1. Logical framework - Results based matrix 19 Annex 2. Situational analysis 42 List of Figures Figure 2. Annual national median stunting rates 2001-2009 4 women and children 2009 4 Figure 6. Trends in wasting, stunting and underweight by livelihood group, 2001-2008 44 Map List of Tables Table 2. Existing programmes presenting opportunities for the integration and 1 Executive Summary and survival of the population. Situational analysis shows a long term nutrition crisis characterised by persistently high rates of acute and chronic malnutrition throughout the country with some and insecurity, with breakdown in social and public services coupled with recurrent droughts and acute malnutrition, nutrition programming coordinated by the Nutrition Cluster, has been primarily focussed on the immediate needs of saving lives through the management of acute malnutrition, based on seasonal assessments of food security and nutrition surveillance data primarily by FSNAU. However, surveillance data shows that even in years of improved food production and relative stability, rates of acute and chronic malnutrition remain high in certain regions indicating other maternal feeding and care practices, low dietary diversity, poor hygiene, water and sanitation, high morbidity coupled with inadequate access to health care are key determinants of the problem. To address these multi-factorial and overlapping causes, a holistic package of interventions with multi-sector collaboration is required. This strategy has been developed via a consultative approach between UN agencies, local and international NGOs and the national and regional health authorities to provide an agreed upon framework for action to meet this need for a shift to a more holistic approach. The results-based strategy provides a detailed action plan to guide prioritisation of interventions situational analysis, review of best practices and proven effective interventions feasible in the challenging context of Somalia, the following goal and outcomes for the strategy have been established. Overall of the strategy is: To contribute to improved survival and development of Somali people through enhanced nutritional status. Outcome 1: Improved access to and utilisation of quality services for the management of malnutrition in women and children Outcome 2: Sustained availability of timely and quality nutrition information and operational research into effective responses to the causes of undernutrition Outcome 3: Increased appropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition Outcome 4: Improved availability and coverage of micronutrients and de-worming interventions to the population Outcome 5: Improved mainstreaming of nutrition as a key component of health and other relevant sectors Outcome 6: Improved capacity and means in country to deliver essential nutrition services Implementation of the strategy will be guided by the overarching principle of improving partnerships between all stakeholders – local and national authorities, donors, UN agencies, local and international NGOS, local community and the private sector – and increased collaboration 2 between sectors. While the main entry point will be through the strengthening of existing structures and services, the strategy also explores new avenues for the provision of services, for example, Due to constraints to rapid scale up of interventions (restrictions in access, logistic, human and are focused on the adaption and standardisation of tools, training and strengthening of structures and mechanisms in preparation for delivery of interventions in the subsequent years (Phase 2). The strategy is consistent with the United Nations Transition Plan (UNTP) for Somalia 2008-09 and has been included in the Reconstruction and Development Plan (RDP) for the next three years. and mortality as outcome indicators. Instead, the results matrix gives details of the output and effectiveness of the strategy will be measured. The progress made in the implementation of the strategy will be reviewed and updated on an annual basis. The inter-agency review process will Committee and undertaken with all stakeholders including regional line ministries. Annual review help inform and identify funding priorities. 3 Since the collapse of central government in 1991 and the resulting civil war, there have been many efforts to restore a central government in Somalia without sustained success. In 1991, the North west zone (NWZ) declared the independent state of Somaliland, with its governing administration in the capital Hargesia. The North east Zone (NEZ) declared itself as the autonomous region of Puntland in 1998. Although governed by its administration in its capital Garowe, it pledges to participate in any Somali reconciliation and reconstruction process that should occur. In South and support a central governing entity. A detailed situational analysis of the nutrition situation in country, determinants of malnutrition and current nutrition interventions, strengths, weaknesses, opportunities and threats can be found in annex 2. In brief, eighteen years of war and insecurity have had devastating effects on the nutrition and health status of the people of Somalia, which was already precarious even before. extreme poverty, coupled with very low basic social service coverage, has seriously affected food in every twelve dies before the age of one year while one child in seven dies before the age of 1.1 Nutrition situation Rates of acute malnutrition and chronic malnutrition are alarming throughout the country with some variations by zone and livelihood system. The most recent assessment from FSNAU Post Deyr ‘09/10 found a national median global acute malnutrition (WHZ < -2 SD) rate of 16%, These rates correspond to an estimated 240,0001 acutely malnourished and one in twenty two, severely malnourished. In addition, according to the previous FSNAU seasonal assessment post Gu 2009, 84,000 pregnant and lactating women are estimated to be acutely malnourished. Preliminary results from FSNAU meta analysis of data from 2001 to 2009 highlight the chronic nature of this alarming situation. The results show that over this period, median rates of global acute malnutrition have remained at Serious Critical throughout (Figure 1), with a national median rate of 16%. Furthermore, annual national median rates of stunting were above 20% ie at serious BACKGROUND1 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr 2001 2002 2003 2004 2005 2006 2007 2008 2009 GAM SAM Figure 1: Seasonal trends in national median rates acute malnutrition 2001-2009 - Source FSNAU 4 Preliminary results of the meta-analysis also highlight how the situation has been consistently worse in South Central Somalia than Puntland or Somaliland. In South Central Somalia, median rates wasting 18%; this compares to 20% the devastating effect of chronic political Somalia in particular. Rates of malnutrition also vary according results of the FSNAU meta analysis of data 2001-2008 revealed that riverine and agro-pastoralist groups had the highest median rate of wasting, stunting and underweight suggesting a higher drought, displacement, disease outbreak. Rates of malnutrition among the urban public services including health. and Anthropometric Nutrition survey 2009 in all three zones, has highlighted public health problem throughout Somalia. The prevalence of both nutritional women and children of all age groups was found to be above WHO thresholds for classifying a severe situation in each 1.2 Determinants of malnutrition model of causes of malnutrition (page 16) provides a useful framework for the discussion of the causes of malnutrition in Somalia. The volatile political situation and civil unrest have led to a chronic and continuing humanitarian crisis that is at the root of the high prevalence of malnutrition resulting in inadequate access to and availability of food at household level. 13.3 16.85 14.15 15.8 20.0 19.0 18.2 29.65 26.7 0 5 10 15 20 25 30 35 Wasting Stunting Underweight M ed ia n pr op or tio n (% ) NW NE SC Source FSNAU data Figure 3: Malnutrition rates by Zone in Somalia (2001-2008) 0 10 20 30 40 50 60 70 80 90 100 Anaemia Vit A deficiency pr ev al en ce % 6-59mths school aged children pregnant women non-pregnant women all women amongst children and women Figure 2: Annual National Median Stunting rates 2001-2009 0% 5% 10% 15% 20% 25% 30% 35% 40% 2001 2002 2003 2004 2005 2006 2007 2008 2009 st u n ti n g r at e % Year 5 However, even in years of relative stability and improved food production, the malnutrition rates in some regions of Somalia have been consistently high, pointing to the important role of other underlying causes. These include sub optimal infant, young child and maternal feeding and care practises as and Anthropometric Nutrition Survey and utilisation of quality health services The water and sanitation situation is poor. Feeding, care and hygiene practices are inadequate not only due to lack of public services but indicating the low coverage of some of these key determinants. Each is discussed in more detail in the situational analysis attached (annex 2). 1.3 Nutrition interventions Due to inadequate governance structures in parts of Somalia, nutrition response programming is mainly undertaken by UN, international and national NGOs. Nutrition interventions are primarily focussed on responding to alarming rates of acute malnutrition throughout the country. Food security and nutrition surveillance and early warning reports (FSNAU, FEWSNET, WFP) are key activities providing quality information and analysis for the targeting of appropriate and timely responses to changing needs in country. Outpatient therapeutic feeding programmes (OTPs) for the management of severe acute malnutrition are being implemented across Somalia by international NGOs and UNICEF in partnership with local NGOs, according to operational guidelines that take into account the challenging environment, reduced supervision and limited monitoring. Targeted supplementary feeding programmes (SFPs) for the management of moderately supplementary food by WFP to all children under-two and pregnant and lactating women, through clinics are supported. In addition, in 2009, UNICEF launched a new initiative for the prevention use food (Plumpy Doz) every two months in areas showing the highest malnutrition rates. Baidoa MCH, UNICEF Somalia, CK Minihane 0 10 20 30 40 50 60 70 80 90 100 ,Increased feeding during diarrhoea 0-59 mths !Prevalence of diarrhoea 0-59 mths Access to improved water source Vitamin A coverage 6-59mths %Immunisation coverage DPT 6-23 months ntroduction of solids, semi solids, soft food 6-8mths "Continued breastfeeding to 24 mths 3Early initiation of breastfeeding (within 1st hour) #Exclusive breastfeeding upto 6 mths prevalence % Figure 5: Prevalence of indicators of some key determinants of malnutrition in Somalia Source: Micronutrient Survey2009 6 Furthermore WFP is providing food assistance to vulnerable groups through institutional feeding affected by the humanitarian crisis, the urban poor and IDPs. In 2009 this food assistance covered seasonal assessments. Nutrition interventions delivered through health campaigns include vitamin A distribution, deworming and nutritional screening during bi annual Child Health Days. Furthermore, nutrition and hospitals. Coverage and quality is currently limited due to overall weaknesses of the public health system. 7 Map 1: Somalia - Nutrition Treatment Interventions in Somalia as of November 2010 2. JUSTIFICATION, SCOPE & GUIDING PRINCIPLES JUSTIFICATION, SCOPE & GUIDING PRINCIPLES 2 inadequate and inequitable social and public services and massive population displacement - but persistently high levels of malnutrition are undermining the survival, growth and development of the population. Rates of acute and chronic malnutrition have consistently exceeded emergency thresholds in some areas for more than 10 years now. Due to the scale of the humanitarian situation interventions are focussed on the management of acute malnutrition. This remains a key priority to prevent associated excess morbidity and mortality. However, the situational analysis shows that in some regions rates of chronic and acute malnutrition remain high even outside of times of crisis, with multi factorial underlying causes. These underlying dietary diversity, inadequate water and sanitation and high morbidity coupled with poor access to and utilisation of health services. These multiple and overlapping determinants of malnutrition in Somalia require a holistic package of interventions delivered through a multi sectoral channels to address the huge public health problem. The range of stakeholders and the variety of approaches response also requires longer term planning, funding and programming. This strategy therefore has been developed to provide an agreed upon framework for action to respond to this need for a shift in approach, whilst continuing to improve the quality of management of acute malnutrition. 2.2 Scope This strategy provides a tool to support co-ordinated action to improve and expand quality nutrition programming in Somalia in a phased approach over the next three years. It is based on a logical framework and is therefore rooted in actions that if conducted produce results that ultimately mean outcomes are accomplished and the overall development goal is achieved. It is intended as an advocacy document for UN agencies and partners to donors. The results-based approach provides an action plan which guides the prioritisation of interventions in a situation of limited resources, integrating interventions. It aims to encourage the development of partnerships between all relevant stakeholders and facilitate cross sector initiatives to address the multi-factorial direct and underlying causes of malnutrition, whilst recognising the challenges of implementation in Somalia 2.3 Guiding Principles Recognition of the basic human right to adequate food and health, for all people to have access to safe and nutritious diets to be free from malnutrition and related disorders. 9 Recognition of the multiple and overlapping causes of malnutrition that require a longer term, cultural factors that determine nutritional status Recognition of the need to build local capacity and resources to respond and promote local ownership existing services and structures as entry points for enhanced interventions. Recognition that the critical window of opportunity for reducing undernutrition and its and Child undernutrition). Interventions after 24 months are much less likely to improve nutritional status and do not reverse earlier damage. that are proven effective in addressing malnutrition (see annex 4). Not all are feasible in the challenging context of Somalia, requiring a less volatile environment, better access, a stronger public health system, legislative framework and longer term funding. The strategy prioritises what is proven effective with what is feasible and can be adapted to the Somali correspond to those acknowledged by the Copenhagen Consensus 2008 as the most cost should not exacerbate or worsen the situation. framework approach. They are based on the priorities, strengths, weaknesses, opportunities approaches adopted are described in annex 6. The overall development goal of this strategy is to contribute to improved survival and development of Somali people through enhanced nutritional status This contribution will be achieved through the accomplishment of the following outcomes (expected GOAL, OUTCOMES & OUTPUTS 3 Outputs: 1.1 Quality services for the management of acute malnutrition are enhanced and expanded 1.2 Quality services for the treatment of expanded populations are enhanced and expanded 1.4 Utilisation of available services for the prevention and treatment of acute and chronic malnutrition is increased Outputs: 2.1 Quality nutritional surveillance, monitoring and evaluation is conducted and reviewed on a timely basis to inform the targeting of vulnerable populations with appropriate responses 2.2 Operational research to identify effective programmes to address the causes of undernutrition is conducted, according to an agreed upon set of priorities and plan of action, and is used as evidence base for long term strategic planning. Child receives ‘Plumpynut’ from father, Concern Worldwide Measuring height during a nutrition survey, FSNAU Outcome 2: Sustained availability of timely and quality nutrition information and operational research into effective responses to address the causes of undernutrition Outcome 1: Improved access to and utilisation of quality services for the management of malnutrition in malnourished women and children 11 Outputs: breastfeeding practices feeding practices of nutrient dense foods are better understood and this knowledge-base is used to promote increased intake of energy, protein and micronutrient-rich foods absorption e.g. tea consumption are better understood and addressed counselling for pregnant and lactating women through health services and community based structures Outputs: 4.2 Improved access to and utilisation of supplementary food by vulnerable groups through health services and novel community based delivery strategies services and d) nutrition programmes Outputs: the policies, strategies, activities, delivery mechanisms and outcomes of health sector strategies, activities, delivery mechanisms and outcomes of relevant sectors (WASH, agriculture/livelihoods, education, food aid) Mother breastfeeding child at Baidoa MCH, UNICEF Somalia, CK Minihane Child receives Vitamin A supplementation at CHD in Hargeisa, UNICEF Somalia, Denise Shepherd Johnson Promotion of handwashing, DHK Mogadishu, SAACID/WFP Outcome 3: Increased appropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition Outcome 4: Improved availability and coverage of micronutrients and de-worming interventions to the population Outcome 5: Improved mainstreaming of nutrition as a key component of health and other relevant sectors 12 Outputs: 6.1 A two year nutrition sector capacity development strategy and plan of action is developed by the end of 2011 6.2 Capacity development strategy and training activities are implemented according to plan of action formed by the end of 2011. 6.4 Internationally recognised training guidelines and protocols are adapted to the Somali context to implement quality nutrition programmes is created and sustained, in collaboration with local authorities Nutrition training, Save the Children in Somalia/ Somaliland Outcome 6: Improved capacity and means in country to deliver essential nutrition services 13 for monitoring progress is included in annex 1. In addition, a results-based matrix detailing the activities, responsible agencies and time frame for action will be developed. Due to constraints a phased approach focused on the adaption and standardisation of tools, training and strengthening of structures and mechanisms in preparation for delivery of interventions in Phase 2. In this way, achievements and challenges of the three zones, implementation of proposed activities will also be phased by geographical location, depending on access, capacity and resources available. 4.1 Opportunities Restricted access, poor infrastructure and limited means in the face of huge needs means innovative ways of intervening in Somalia are called for. Opportunities arise from existing structures, pilots and programmes which provide entry points for strengthening, scaling up and delivering complementary essential activities. These opportunity areas are summarised below with more detail found in Table 2 of the situational analysis. nutrition programmes which provide existing structures through which to deliver essential complementary services (deworming, immunisation, promotion of good GAVI Health System Strengthening (HSS) funded Female Community-based Health Workers Plumpy doz for prevention of moderate malnutrition Somali context City Initiatives – community structures already in place as the basis for community based interventions. population based interventions such as deworming, micronutrient supplementation and nutrition education. IMPLEMENTATION4 OTP nurse explaining healthy messages to OTP attendants, Baadbuke OTP site Save the Children 14 4.2 Partnerships Implementation of the strategy will be through partnership-based action, with the national and NGOs and civil society, with the international community and with the private sector. a) National and local government Throughout the three zones, but more so in Somaliland and Puntland, government structures are in place and evolving. Governments have the responsibility to provide policy direction and leadership, promote inter-ministerial collaboration and advocate with religious and cultural institutions in priority areas. However, capacity is currently inadequate. In response to this, a key output of this strategy is to support the improvement of local capacity and structures within the b) The Community In areas where continuing insecurity and lack of access for international staff persists, implementation through local authorities, local NGOs and community based workers will be funds, the development of the role of the community health worker is essential for community mobilisation, individual support and promotion of good nutrition, hygiene and health practices. Furthermore the system of female community-based health workers proposed through GAVI HSS partum women, prevention and control of diarrhoea, promotion of early initiation and exclusive breastfeeding and appropriate complementary feeding practices for infants and young children, promotion of good nutrition for all the family in particular women, assessment of nutritional status and referral of malnourished children. Schools, religious and cultural institutions provide important structures within the community and referral of acute malnutrition and nutrition education. c) Local Non Governmental Organisations (NGOs) are very important partners in the delivery of interventions where access to the international community is restricted and government structures are weak. Again, capacity is often a limiting factor and is one of the priority areas to be addressed, in line with national and regional as well as UN national capacity development strategies. The development of regional training and mentoring cells will be an important initiative in improving capacity and the quality of nutrition programmes implemented by these local partners. d) International community Donors Over recent years, work by FSNAU has achieved a tremendous amount in highlighting the devastating nutrition situation in country and as a consequence, donor funding of emergency programmes has been good. The challenge is to keep nutrition as a priority for donors, UN, NGOs and the ministries and advocate for a longer term strategy in Somalia to address not only the critical acute malnutrition situation but also the underlying causes, if reduced mortality and optimal growth and development are to be addressed. United Nations (UN) This strategy will build on the already strong collaboration between United Nations (UN) agencies such as UNICEF, FAO/FSNAU, WFP, UNFPA and WHO working to improve maternal and child nutrition and health in Somalia. One key area of collaboration is around strengthening mechanisms to ensure a minimum package of essential services is delivered 15 alongside nutrition programmes in a timely manner. Under UN humanitarian reform, the cluster approach has been developed to strengthen coordination and give predictability and accountability to the humanitarian response. There are education, nutrition, protection, logistics and shelter and currently inter cluster working group coordination meetings are held. This strategy places great importance on improving inter cluster and inter working group collaboration for a multi-sector approach to addressing the cross cutting factors that determine nutritional status, growth and development in Somalia. International Non-Governmental Organizations (NGOs) Although access may be restricted, International NGOs continue to be important partners providing additional technical capacity and skills in nutrition and new innovations in programme delivery. Academic, Research and Global Advocacy Institutions: A new area to be explored is to access expertise from internationally recognized organizations and improve linkages with local c) The Private Sector The private sector in Somalia has an important potential contribution to make towards improving the nutrition situation in country. One of the key areas to engage with the private sector on is the control of the marketing and promotion of breast milk substitutes, possibly looking at supporting the private sector to promote appropriate complementary foods to prevent malnutrition in place of infant formula. Advocacy and sensitisation of the private sector on the International Code on process on its adoption. The private sector also has a key role to be explored in the potential developing private public partnerships in the social marketing of micronutrient supplements as treated bed nets in Somaliland. 4.3 Zonal differences The overall goal and outcomes are the same for Somaliland, Puntland and South Central Somalia but the situational analysis provides evidence of the need for a different approach to implementation in the different zones. Coverage of services for the management of acute striving for improved quality of services is particularly important in South Central Somalia where rates of acute malnutrition were found to be the highest of all zones in the recent Post deyr 09/10 humanitarian space to intervene is most restricted. To overcome these challenges, there is a need to concentrate on implementing through local NGOs and community-based initiatives as government structures emerge and evolve. Until the situation becomes more secure, programmes must be managed by remote control and innovative mechanisms for delivery of interventions to be started on a smaller local basis, to be scaled up as the political and security situation allows. 16 In Somaliland and to a lesser extent Puntland, more or less stable government institutions have been formed providing greater opportunities for partnerships. However as yet, capacity, coordination and policy or regulatory framework is limited. The relative peace and stability allows greater access for intervention, monitoring and supervision. In the north, support needs to focus on the increasing numbers of IDPs who, despite some improvement in acute malnutrition rates between Post Gu 09 and Post Deyr down from 4.8% to 4.2%) remain one of the most nutritionally vulnerable group of all livelihoods, with 4.4 Operational research Although extensive information is gathered through FSNAU, FEWSNET, WFP food security and consumption of nutrient dense foods, enabling factors and barriers to optimal breast feeding, young child and maternal feeding practices, economic and cultural dynamics of breast milk substitutes, opportunities for engagement with private sector in areas of breast milk substitutes and food innovative population based delivery mechanisms for micronutrient supplementation, deworming, nutrition education and behaviour change communication. and guide appropriate intervention and links with achieving output 2.2. 4.5 Technical support There will be a need to commission consultants with particular expertise in certain areas including current situation, identify potential for future interventions and formulate action plans. 4.6 Behaviour Change Communication and behaviour change on an individual and community basis (early initiation of and exclusive breastfeeding for 6 months, optimal complementary feeding practices, food safety, increased dietary diversity, hygiene practices, demand for micronutrient supplementation and reduction of practices inhibiting micronutrient absorption, appropriate health and nutrition seeking behaviours). There is often overlap with priorities of other sectors eg promotion of food safety goes hand in hand with good hygiene practices. In response, a comprehensive and integrated behaviour change communication strategy approach is needed with the development of key simple on an individual basis through interpersonal counselling by community health workers and breast feeding counsellors, and mobilising communities through mosques, schools and local institutions and mass media campaigns. Breastfeeding Counselling, IDPs, Hargeisa, UNICEF Somalia, Iman Morooka MONITORING5 nutrition surveillance data. However, because three years is too short a period in which to see have been achieved. The results matrix gives details of the output and outcome (impact) and activity (process) indicators were technical issues with the quality of nutrition data in particular, and is planned for 2011 and has been of low quality and irregular but for which there are ongoing efforts to improve quality valuable baseline information on a number of key indicators. To facilitate the coordination and The strategy will be reviewed and updated on a regular basis not least because the security and access situations can change substantially in Somalia thereby affecting feasibility of implementation. The inter-agency review process of progress on implementation will be led by undertaken with the involvement of all stakeholders. Line ministries will have a key input into the priorities for CAP. Reports on progress will be disseminated to donors, national and implementation partners on an annual basis. A full review of progress made in the implementation of the strategy ANNEXES 18 19 P ro je ct d es cr ip ti on In di ca to rs S ou rc e of v er if ic at io n A ss um pt io ns G oa l: T o co nt rib ut e to im pr ov ed s ur vi va l a nd d ev el op m en t o f S om al i p eo pl e th ro ug h en ha nc ed n ut rit io na l s ta tu s O ut co m e 1: Im pr ov ed a cc es s to a nd u til is at io n of q ua lit y se rv ic es fo r th e m an ag em en t o f m al nu tr iti on in w om en a nd ch ild re n 1a 7 5% a cu te ly m al no ur is he d ch ild re n an d pr eg na nt a nd la ct at in g w om en h av e ac ce ss to a nd u til is e qu al ity s er vi ce s fo r m an ag em en t o f a cu te m al nu tr iti on 1b N um be r of h ea lth fa ci lit ie s pr ov id in g se rv ic es fo r th e tr ea tm en t o f m ic ro nu tr ie nt de fic ie nc ie s w ith s ta nd ar di se d pr ot oc ol s, tr ai ne d st af f, ad eq ua te a nd ti m el y su pp lie s 1c 5 0% id en tif ie d hi gh r is k po pu la tio ns ha ve a cc es s to a nd u se n ut rie nt d en se su pp le m en ta ry fo od to p re ve nt un de rn ut rit io n N ut rit io n pr og ra m m e pe rf or m an ce in di ca to rs da ta ba se F S N A U s ur ve ill an ce d at a C ov er ag e su rv ey s (li m ite d) H M IS , M oH r ec or ds , fa ci lit y ba se d su rv ey (G A V I H S S ) A cc es s to fu nc tio ni ng h ea lth se rv ic es A cc es s to fo od s ec ur ity A cc es s to h ea lth y en vi ro nm en t A ut ho rit ie s, li ne m in is tr ie s, ar m ed g ro up s ar e su pp or tiv e an d pr ov id e ne ce ss ar y co nd iti on s fo r im pl em en ta tio n O ut pu ts : 1. 1 Q ua lit y se rv ic es fo r th e m an ag em en t o f a cu te m al nu tr iti on a re e nh an ce d an d ex pa nd ed 1. 2 Q ua lit y se rv ic es fo r th e tr ea tm en t o f m ic ro nu tr ie nt d ef ic ie nc ie s ar e en ha nc ed a nd ex pa nd ed 1. 1a 70 % o f t ar ge ts s et fo r en ha nc em en t & e xp an si on o f o pe ra tio na l S C s, O T P s & S F P s ba se d on b i a nn ua l si tu at io na l a na ly si s, a re m et 1. 1b 70 % o f p ar tn er s op er at in g w ith pe rf or m an ce in di ca to rs th at m ee t S P H E R E s ta nd ar ds 1. 2 N um be r of h ea lth fa ci lit ie s pr ov id in g se rv ic es fo r th e tr ea tm en t of m ic ro nu tr ie nt d ef ic ie nc ie s w ith Im pl em en tin g ag en ci es ’ re po rt s Im pl em en tin g ag en ci es ’ re po rt s U N IC E F d at ab as e H M IS , M oH r ec or ds F ac ili ty b as ed s ur ve y (G A V I H S S 4 0 M C H P ip el in e fu nd ed & im pl em en te d S ec ur ity a llo w s ac ce ss fo r im pl em en tin g ag en ci es to op er at e S ec ur ity a llo w s ac ce ss fo r be ne fic ia rie s B en ef ic ia rie s w ill in g an d ab le to s ee k ca re F un ct io ni ng h ea lth fa ci lit ie s LOGICAL FRAMEWORKANNEX 1 1. 3 F oo d ba se d in te rv en tio ns fo r th e pr ev en tio n of un de rn ut rit io n in id en tif ie d hi gh r is k po pu la tio ns ar e en ha nc ed a nd e xp an de d, th ro ug h th e he al th s er vi ce s an d co m m un ity b as ed st ru ct ur es 1. 4 U til is at io n of a va ila bl e se rv ic es fo r th e pr ev en tio n an d tr ea tm en t o f a cu te a nd c hr on ic m al nu tr iti on is in cr ea se d st an da rd is ed p ro to co ls , t ra in ed st af f, ad eq ua te a nd ti m el y su pp lie s in r el at io n to n ee d 1. 3 5 0% r eg is te re d/ el ig ib le c hi ld re n in se le ct ed in te rv en tio n ar ea s re ce iv e nu tr ie nt d en se s up pl em en ta ry fo od 1. 4 % r eg is te re d/ el ig ib le c hi ld re n us in g av ai la bl e se rv ic es in cr ea se s by x % ce nt re s + 8 0 H ea lth po st s) H ea lth c ar e pr ov id er s tr ai ni ng d at ab as e 1 Im pl em en tin g ag en ci es pr og ra m m e re po rt s Im pl em en tin g ag en ci es ’ re po rt s S ec ur ity s itu at io n al lo w s ac ce ss fo r im pl em en tin g ag en ci es a nd b en ef ic ia rie s S ec ur ity s itu at io n al lo w s ac ce ss fo r im pl em en tin g ag en ci es a nd r ec ip ie nt s A ct iv iti es : 1. 1. 1 B as ed o n bi a nn ua l r ev ie w o f n ut rit io n si tu at io n, as se ss n ee ds , s et ta rg et s an d es ta bl is h ne w se rv ic es fo r en ha nc em en t & e xp an si on o f op er at io na l S C s, O T P s & S F P s 1. 1. 2 P ro vi de s up pl ie s an d te ch ni ca l s up po rt o n a tim el y ba si s 1. 1. 3 D ev el op a nd im pl em en t M A M g ui de lin es sp ec ifi c to S om al i c on te xt , i nc lu di ng s pe ci al at te nt io n to n om ad ic c om m un iti es 1. 1. 4 C on du ct c om m un ity m ob ili sa tio n w ith de di ca te d st af f a nd r es ou rc es to in cr ea se co ve ra ge & e ar ly d ia gn os is 1. 1. 5 S ta nd ar d nu tr iti on p ro gr am m e pe rf or m an ce in di ca to rs a re r ep or te d m on th ly 1. 1. 1 i) N ee ds a ss es se d an d ta rg et s se t ev er y si x m on th s, ii ) N ew s er vi ce s ar e in p la ce a nd o pe ra tio na l 1. 1. 2 nu m be r of d ay s st oc k ou ts 1. 1. 2b S P H E R E s ta nd ar ds fo r pr og ra m m e qu al ity a re m et b y 70 % p ar tn er s 1. 1. 3 gu id el in es a re d ev el op ed a nd ac tiv el y ad op te d by 8 0% o f pa rt ne rs 1. 1. 4 a) n um be r of c om m un ity m ob ili sa tio n ca m pa ig ns co nd uc te d b) p ro po rt io n of co m pl ic at ed to u nc om pl ic at ed S A M c as es 2 1. 1. 5 80 % im pl em en tin g ag en ci es re po rt in g m on th ly M ee tin g re po rt s of r ev ie w an d ta rg et s se t Im pl em en tin g ag en ci es re po rt s H M IS , U N IC E F & W F P su pp ly d at a U N IC E F d at ab as e P ub lis he d gu id el in es , im pl em en tin g pa rt ne rs re po rt s Im pl em en tin g pa rt ne rs re po rt s U N IC E F d at ab as e S ec ur ity s itu at io n al lo w s ac ce ss fo r su rv ei lla nc e, im pl em en ta tio n an d ut ili sa tio n of s er vi ce s A de qu at e hu m an , f in an ci al an d m at er ia l r es ou rc es av ai la bl e E ffi ci en t l og is tic s sy st em fo r tim el y de liv er y of a de qu at e su pp lie s N ew g ui de lin es a cc ep te d an d ad op te d by p ar tn er s T ar ge t p op ul at io n op en to m es sa ge s R ep or ts a re r el ia bl e 20 1. 1. 6 A dv oc at e to e ns ur e de liv er y of b as ic e ss en tia l he al th s er vi ce s (i m m un is at io n, d e w or m in g et c) th ro ug h nu tr iti on p ro gr am m es 1. 2. 1 R ev ie w m ic ro nu tr ie nt s ur ve y re su lts a nd H M IS da ta w he re a va ila bl e an d se t t ar ge ts fo r en ha nc em en t o f M N D tr ea tm en t s er vi ce s 1. 2. 2 D ev el op & im pl em en t s im pl e S om al i s pe ci fic st an da rd is ed p ro to co ls fo r th e tr ea tm en t o f m ic ro nu tr ie nt d ef ic ie nc ie s, w ith r eg io na l r ol l o ut 1. 2. 3 D ev el op a nd im pl em en t s im pl e st an da rd is ed pr ot oc ol fo r th er ap eu tic z in c su pp le m en ta tio n in th e m an ag em en t o f d ia rr ho ea 1. 2. 4 P ro vi de a nd m an ag e su pp lie s an d pr ov id e te ch ni ca l s up po rt o n a tim el y ba si s 1. 2. 5 P la n an d im pl em en t i n s er vi ce tr ai ni ng o f he al th fa ci lit y st af f a t a ll le ve ls o n d ia gn os is a nd tr ea tm en t p ro to co ls 1. 2. 6 C on du ct c om m un ity m ob ili sa tio n ca m pa ig ns o n M N D 1. 3. 1 A ss es s ne ed s an d id en tif y vu ln er ab le po pu la tio ns th ro ug h bi a nn ua l r ev ie w o f q ua lit y nu tr iti on a nd fo od s ec ur ity s ea so na l as se ss m en ts 1. 3. 2 B as ed o n ab ov e, e st ab lis h ne w n ut ri tio n se rv ic es fo r pr ev en tio n of u nd er nu tr iti on , 1. 1. 6 A dv oc ac y is c ar ri ed o ut 1. 2. 1 S ur ve y re su lts a nd H M IS d at a re vi ew ed a nd ta rg et s se ts 1. 2. 2 a) S ta nd ar di se d pr ot oc ol s de ve lo pe d by e nd o f ph as e 1 b) in cr ea si ng tr en ds in x % h ea lth fa ci lit ie s im pl em en tin g tr ea tm en t pr ot oc ol s ac ro ss th e re gi on s3 1. 2. 3 a) S ta nd ar di se d pr ot oc ol s de ve lo pe d by e nd o f ph as e 1 b ) 80 % c hi ld re n at te nd in g M C H ex pe ri en ci ng d ia rr ho ea w ho re ce iv e th er ap eu tic z in c su pp le m en ta tio n by e nd p ha se 2 1. 2. 4 N um be r of d ay s of s to ck o ut s of m ic ro nu tr ie nt tr ea tm en ts 1. 2. 5 a) N um be r of h ea lth fa ci lit ie s w ith st af f t ra in ed a nd a ct iv e in tr ea tm en t o f m ic ro nu tr ie nt de fic ie nc ie s 1. 2. 6 N um be r of c am pa ig ns c on du ct ed 1. 2. 1 B i a nn ua l r ev ie w c on du ct ed a nd ta rg et p op ul at io ns id en tif ie d 1. 2. 2 F oo d ba se d in te rv en tio ns to pr ev en t u nd er nu tr iti on a re D oc um en ta tio n D oc um en ta tio n D oc um en ta tio n H M IS F ac ili ty s ur ve y D oc um en ta tio n H M IS H M IS s up pl y da ta N ew d at ab as e on h ea lth pe rs on ne l & tr ai ni ng re ce iv ed A ct iv ity r ep or ts R ep or ts o f r ev ie w a nd ta rg et s id en tif ie d Im pl em en tin g ag en ci es re po rt s H ea lth s ec to r re ce pt iv e, ad eq ua te s up pl ie s an d lo gi st ic s ys te m a va ila bl e R es ul ts a re r el ia bl e S uf fic ie nt s up pl ie s an d ef fic ie nt lo gi st ic al s up po rt av ai la bl e H ea lth fa ci lit y st af f m ot iv at ed C om m un ity r ec ep tiv e D at a an d re vi ew a re r el ia bl e S up pl em en ta ry fo od s ar e ac ce pt ab le to a nd u se d 21 22 (in cl ud in g lip id b as ed n ut rie nt s up pl em en ts LN S ) i n id en tif ie d hi gh ri sk p op ul at io ns 1. 3. 3 C on du ct tr ai ni ng o f h ea lth w or ke rs a nd im pl em en tin g pa rtn er s on n ew s er vi ce s, in cl ud in g co un se lli ng o n co nt in ue d br ea st fe ed in g an d fo od h yg ie ne p ra ct ic es 1. 3. 4 P ro vi de a nd m an ag e su pp lie s an d pr ov id e te ch ni ca l s up po rt to im pl em en tin g pa rtn er s on a tim el y ba si s 1. 3. 5 C on du ct c om m un ity s en si tis at io n to m ax im is e ac ce pt ab ili ty a nd a pp ro pr ia te u se o f f oo d ba se d in te rv en tio ns 1. 3. 6 A ss es s an d re vi ew c on tin ua tio n of fo od b as ed in te rv en tio ns , b as ed o n nu tri tio n su rv ei lla nc e da ta a nd b i a nn ua l s ea so na l a ss es sm en ts 1. 4. 1 C on du ct c om m un ity a w ar en es s an d m ob ili sa tio n ca m pa ig ns to in cr ea se a w ar en es s an d un de rs ta nd in g of a va ila bl e se rv ic es es ta bl is he d in id en tif ie d hi gh ri sk ar ea s 1. 2. 3 N um be r o f h ea lth w or ke rs a nd im pl em en tin g st af f t ra in ed 1. 2. 4 N um be r o f d ay s of s to ck o ut s 1. 2. 5 N um be r o f c om m un ity se ns iti sa tio n ca m pa ig ns co nd uc te d 1. 2. 6 B i a nn ua l r ev ie w s co nd uc te d 1. 4. 1 n um be r o f c om m un ity c am pa ig ns co nd uc te d Tr ai ni ng re po rts , h ea lth w or ke r t ra in in g da ta ba se , pa rtn er re po rts S up pl y da ta A ct iv ity re po rts R ev ie w re po rts A ct iv ity re po rts ap pr op ria te ly b y ta rg et gr ou ps H ea lth w or ke rs a nd pr og ra m m e st af f a re m ot iv at ed S uf fic ie nt s up pl ie s an d ef fic ie nt lo gi st ic s sy st em in pl ac e C om m un ity is re ce pt iv e S ur ve ill an ce d at a is re lia bl e C om m un ity is re ce pt iv e 23 O u tc o m e 2 P ro je ct d es cr ip ti o n In d ic at o rs S o u rc e o f ve ri fi ca ti o n A ss u m p ti o n s O u tc o m e 2 : S u st a in e d a va ila b ili ty o f tim e ly a n d q u a lit y n u tr iti o n in fo rm a tio n a n d o p e ra tio n a l r e se a rc h in to e ff e ct iv e re sp o n se s to a d d re ss t h e c a u se s o f u n d e rn u tr iti o n N u m b e r o f in fo rm a tio n u se rs (g o ve rn m e n t, in st itu tio n s, c iv il so ci e ty , D ia sp o ra , IN G O s, U N a g e n ci e s, d o n o rs , o th e rs ) re ce iv in g n u tr iti o n in fo rm a tio n t o in cr e a se b y 4 0 % a ft e r 3 y e a rs N u m b e r o f in fo rm a tio n u se rs b a se d in S o m a lia r e ce iv in g n u tr iti o n in fo rm a tio n t o in cr e a se b y 4 0 % a ft e r 3 y e a rs E vi d e n ce o f F S N A U a n a ly si s b e in g p ri m a ry in fo rm a n t to h u m a n ita ri a n a p p e a l a n d r e sp o n se p ro ce ss a n d e vi d e n ce o f ch a n g e s in t h e r e sp o n se a n d p ro ce ss (C A P /H R F /C E R F ) E vi d e n ce o f n u tr iti o n a n a ly si s in fo rm in g th e R e co n st ru ct io n & D e ve lo p m e n t P la n (R D P ), U n ite d N a tio n s T ra n si tio n P la n (U N T P ), A g ri cu ltu re S e ct o r S tr a te g ic F ra m e w o rk ( A S S F ), a n d C o u n tr y S tr a te g y P a p e r (C S P ) a n d e vi d e n ce o f ch a n g e s in th e d e si g n a n d m o n ito ri n g o f th e se in iti a tiv e s E vi d e n ce o f n u tr iti o n a n a ly si s in fo rm in g th e S o m a lia S u p p o rt S e cr e ta ri a t (S S S ) S o m a lia n u tr iti o n in fo rm a tio n a g e n cy w e b si te h its ( F S N A U , U N IC E F , W H O , O C H A ), m a ili n g li st s, m e e tin g p a rt ic ip a tio n , n u tr iti o n u n it o f M o H s C A P , C E R F , H R F re p o rt s R D P d o cu m e n t C lu st e r m e e tin g P a rt n e rs a n d d o n o rs re ce p tiv e t o n u tr iti o n in fo rm a tio n N u tr iti o n in fo rm a tio n is in te rp re te d a p p ro p ri a te ly t o in fo rm d e ci si o n s re g a rd in g fe a si b le r e sp o n se s S e cu ri ty s itu a tio n a llo w s a cc e ss t o r e sp o n d t o n u tr iti o n in fo rm a tio n a va ila b le A u th o ri tie s, li n e m in is tr ie s, a rm e d g ro u p s a re su p p o rt iv e a n d p ro vi d e n e ce ss a ry c o n d iti o n s to re sp o n d 24 se ct o r w o rk in g g ro u p s a n d t h e I A S C C lu st e r a ct io n p la n s a n d e vi d e n ce o f d e ci si o n s in flu e n ce d b y th is a n a ly si s N u tr iti o n a n a ly si s a n d in fo rm a tio n co n tr ib u tin g t o 5 0 % o f th e s e ct o r st u d ie s a n d s tr a te g ic p la n n in g u n d e rt a ke n b y S o m a li g o ve rn m e n t, d o n o rs , U N a g e n ci e s, I N G O s m in u te s S tr a te g ic p la n n in g re p o rt s O u tp u ts : 2 .1 Q u a lit y n u tr iti o n a l s u rv e ill a n ce , m o n ito ri n g a n d e va lu a tio n is c o n d u ct e d a n d r e vi e w e d o n a t im e ly b a si s to in fo rm t h e t a rg e tin g o f vu ln e ra b le p o p u la tio n s w ith a p p ro p ri a te r e sp o n se s 2 .2 O p e ra tio n a l r e se a rc h t o id e n tif y e ff e ct iv e p ro g ra m m e s to a d d re ss t h e c a u se s o f u n d e rn u tr iti o n is c o n d u ct e d , a cc o rd in g t o a n a g re e d u p o n s e t o f p ri o ri tie s a n d p la n o f a ct io n , a n d is u se d a s e vi d e n ce b a se f o r lo n g t e rm s tr a te g ic p la n n in g 2 .1 a 1 0 0 % s u rv e ys a re v a lid a te d u si n g p la u si b ili ty c h e ck s. 2 .1 b > 9 0 % o f su rv e ys m e e t th e c ri te ri a o f q u a lit y fo r p u b lis h in g r e su lts 2 .1 b R e su lts o f b ia n n u a l n u tr iti o n a ss e ss m e n ts a re r e le a se d a n d r e vi e w e d in J a n u a ry ( p o st D e yr ) a n d A u g u st ( p o st G u ) o f e a ch y e a r 2 .2 x % r e se a rc h p ro je ct s u n d e rt a ke n a cc o rd in g t o d e fin e d p la n o f a ct io n 4 F S N A U t e ch n ic a l s e ri e s re p o rt s D o cu m e n ta tio n o f F S N A U s e a so n a l a ss e ss m e n t re le a se d a te s D o cu m e n ta tio n o f n u m b e r o f re se a rc h re p o rt s p ro d u ce d D a ta c o lle ct io n is r e lia b le A ct iv iti e s 2 .1 .1 C o n d u ct r e g u la r in te r a g e n cy n u tr iti o n s u rv e ys th ro u g h o u t liv e lih o o d z o n e s a cc o rd in g t o a g re e d u p o n s ch e d u le a n d in te r se ct o ra l in fo rm a tio n r e q u ir e m e n ts . 2 .1 .1 a > 9 0 % p la n n e d n u tr iti o n s u rv e ys co n d u ct e d 2 .1 .1 b P a rt n e rs in vo lv e d in 1 0 0 % o f th e su rv e ys f o r o w n e rs h ip 2 .1 .1 c 1 0 0 % p re a g re e d in te r se ct o ra l F S N A U t e ch n ic a l s e ri e s re p o rt s, B i m o n th ly N u tr iti o n U p d a te s S e cu ri ty s itu a tio n a llo w s a cc e ss S u ff ic ie n t fin a n ci a l, h u m a n re so u rc e s a n d m a te ri a l 25 2. 1. 2 A na ly se s ur ve y re su lts a nd in te rp re t i n co nt ex t of o th er r el ev an t s ur ve ill an ce d at a (M C H d at a, av ai la bi lit y of n ut rit io n pr og ra m m es , a cc es s to he al th s er vi ce s, d is ea se o ut br ea ks , w at er a nd sa ni ta tio n, fo od s ec ur ity in fo rm at io n) 2. 1. 3 U nd er ta ke b ia nn ua l m ap pi ng o f n ut rit io n si tu at io n by li ve lih oo d zo ne , a cc or di ng to IP C cl as si fic at io n 2. 1. 4 P ro du ce r eg ul ar n ut rit io n up da te s an d re po rt s in cl ud in g: Q ua rt er ly F oo d se cu rit y an d nu tr iti on br ie f, B ia nn ua l F oo d S ec ur ity a nd N ut rit io n br ie f, bi a nn ua l t ec hn ic al s er ie s re po rt s. 2. 2. 1 P rio rit y ar ea s fo r op er at io na l r es ea rc h in to un de rly in g ca us es o f u nd er nu tr iti on id en tif ie d an d pl an o f a ct io n de vi se d to in cl ud e ac tiv iti es 3. 1. 1, 3 .2 .1 , 3 .3 .1 , 3 .4 .1 , 3 .5 .3 , 4 .2 .6 , 4 .2 .8 2. 2. 2 C on du ct o pe ra tio na l r es ea rc h ac co rd in g to p la n of a ct io n 2. 2. 3 P ro du ce r es ea rc h re po rt s, d is se m in at e an d us e fin di ng s to in fo rm a pp ro pr ia te n ut rit io n re sp on se s in fo rm at io n re qu ire m en ts ( W A S H , H ea lth , M al ar ia , F oo d S ec ur ity ) ad dr es se d 2. 1. 2 10 0% p ub lis he d su rv ey r ep or ts in cl ud e co nt ex tu al a na ly si s 2. 1. 3 M ap s pr od uc ed o n a bi an nu al b as is 2. 1. 4 N ut rit io n re po rt s pr od uc ed a cc or di ng to d ef in ed s ch ed ul e 2. 2. 1 Li st o f p rio rit ie s ar ea s an d pl an o f ac tio n id en tif ie d 2. 2. 2 R es ea rc h is c on du ct ed 2. 2. 3 R es ea rc h re po rt s pu bl is he d an d di ss em in at ed M ap s pr od uc ed R ep or ts p ro du ce d P ub lis he d re po rt s re so ur ce s av ai la bl e Im pl em en tin g pa rt ne rs , au th or iti es , l in e m in is tr ie s, ar m ed g ro up s ar e su pp or tiv e an d pr ov id e ne ce ss ar y co nd iti on s to co nd uc t s ur ve ys & r es ea rc h 26 O u tc o m e 3 P ro je ct d es cr ip ti o n In d ic at o rs S o u rc e o f ve ri fi ca ti o n A ss u m p ti o n s O u tc o m e 3 : In cr e a se d a p p ro p ri a te k n o w le d g e , a tt itu d e s a n d p ra ct ic e s re g a rd in g in fa n t, y o u n g c h ild a n d m a te rn a l n u tr iti o n 5 0 % in cr e a se in a p p ro p ri a te k n o w le d g e , a tt itu d e s a n d p ra ct ic e s re g a rd in g in fa n t, yo u n g c h ild a n d m a te rn a l n u tr iti o n K A P s tu d y M IC S A cc e ss t o f u n ct io n in g h e a lth se rv ic e s A cc e ss t o f o o d s e cu ri ty A cc e ss t o h e a lth y e n vi ro n m e n t O u tp u ts : 3 .1 I m p ro ve d r a te s o f e a rl y in iti a tio n a n d e xc lu si ve b re a st fe e d in g p ra ct ic e s 3 .2 I m p ro ve d r a te s o f o p tim a l c o m p le m e n ta ry f e e d in g p ra ct ic e s 3 .3 L o ca l a va ila b ili ty a n d c o n su m p tio n p a tt e rn s o f n u tr ie n t d e n se f o o d s a re b e tt e r u n d e rs to o d a n d kn o w le d g e b a se is u se d t o p ro m o te in cr e a se d in ta ke o f e n e rg y, p ro te in a n d m ic ro n u tr ie n t ri ch fo o d s 3 .4 C o m m o n p ra ct ic e s th a t in h ib it m ic ro n u tr ie n t a b so rp tio n a re b e tt e r u n d e rs to o d a n d a d d re ss e d 3 .5 I m p ro ve d a cc e ss t o n u tr iti o n c o u n se lli n g f o r p re g n a n t a n d la ct a tin g w o m e n t h ro u g h h e a lth se rv ic e s a n d c o m m u n ity b a se d s tr u ct u re s 3 .1 R a te s o f e a rl y in iti a tio n a n d e xc lu si ve b re a st fe e d in g d o u b le f ro m b a se lin e ( 5 % )5 3 .2 R a te s o f o p tim a l c o m p le m e n ta ry fe e d in g p ra ct ic e s – a g e a t in tr o d u ct io n , d ie ta ry d iv e rs ity , m e a l fr e q u e n cy – d o u b le f ro m b a se lin e (1 1 % )6 3 .3 a ) L o ca l a va ila b ili ty a n d c o n su m p tio n p a tt e rn s o f n u tr ie n t d e n se f o o d s a re id e n tif ie d , d o cu m e n te d a n d u se d in B C C 3 .4 R e d u ct io n in c o m m o n p ra ct ic e s th a t in h ib it m ic ro n u tr ie n t a b so rp tio n (b a se lin e f re q u e n t te a c o n su m p tio n 7 2 % )7 3 .5 a 8 0 % p re g n a n t a n d la ct a tin g w o m e n a tt e n d in g M C H s e rv ic e s a cc e ss n u tr iti o n c o u n se lli n g M IC S , M ic ro n u tr ie n t su rv e y M IC S , F S N A U h o u se h o ld n u tr iti o n a ss e ss m e n t d a ta , C S I – c o p in g s tr a te g ie s in d e x R e p o rt H M IS S e cu ri ty s itu a tio n a llo w s a cc e ss f o r im p le m e n ta tio n a n d u til is a tio n o f se rv ic e s 27 3 .5 b N u m b e r o f p re g n a n t a n d la ct a tin g w o m e n r e ce iv in g n u tr iti o n co u n se lli n g t h ro u g h c o m m u n ity b a se d d e liv e ry m e ch a n is m A ct iv ity r e p o rt s T a rg e t g ro u p s co m p ly w ith a d vi ce A ct iv iti e s: 3 .1 .1 C o n d u ct f o rm a tiv e r e se a rc h t o u n d e rs ta n d cu rr e n t p ra ct ic e s & a ss e ss b a rr ie rs a n d o p p o rt u n iti e s to o p tim a l b re a st f e e d in g p ra ct ic e s 3 .1 .2 D e ve lo p a n d im p le m e n t a n I Y C F t ra in in g p la n a n d c u rr ic u la f o r co m m u n ity b a se d b re a st fe e d in g c o u n se llo rs ( B F C ) a n d M C H st a ff , in cl u d in g t ra in in g o f m a st e r tr a in e rs 3 .1 .3 P ro vi d e in d iv id u a l c o u n se lli n g a n d s u p p o rt f o r e xc lu si ve b re a st f e e d in g t h ro u g h a n e tw o rk o f tr a in e d c o m m u n ity b a se d B F C & M C H s ta ff 3 .1 .4 R e vi e w a n d a d a p t IA S C / E N N /I F E ‘I n te g ra tio n o f IY C F s u p p o rt in to C M A M ’ m a te ri a ls t o t h e S o m a li co n te xt 3 .1 .5 P ilo t In te g ra tio n o f IY C F s u p p o rt in to C M A M a p p ro a ch in s p e ci fie d O T P s 3 .1 .6 D e ve lo p a n d d is se m in a te k e y m e ss a g e s & m a te ri a ls f o r m o b ili si n g c o m m u n ity s u p p o rt f o r o p tim a l b re a st fe e d in g t h ro u g h a p p ro p ri a te d e liv e ry s tr a te g ie s, in cl u d in g g ra n d m o th e rs , re lig io u s/ co m m u n ity g ro u p s a n d le a d e rs a n d m a ss m e d ia c h a n n e ls 3 .1 .7 C o n d u ct m a rk e t ch a in a n a ly si s o f b re a st m ilk su b st itu te s 3 .1 .8 E n g a g e w ith p ri va te s e ct o r a n d d e ve lo p & im p le m e n t a n a d vo ca cy s tr a te g y fo r 3 .1 .1 B a rr ie rs & o p p o rt u n iti e s id e n tif ie d 3 .1 .2 a m a st e r tr a in e rs a re t ra in e d 3 .1 .2 b c u rr ic u lu m is d e ve lo p e d 3 .1 .2 c tr a in in g p la n is im p le m e n te d 3 .1 .3 a n u m b e r o f B F C t ra in e d a n d a ct iv e 3 .1 .3 b n u m b e r M C H c e n tr e s p ro vi d in g b re a st fe e d in g c o u n se lli n g 3 .1 .4 M a te ri a ls a d a p te d b y e n d o f p h a se 1 3 .1 .5 P ilo ts c o n d u ct e d in s p e ci fie d O T P s 3 .1 .6 a I E C m a te ri a ls d e ve lo p e d 3 .1 .6 b M e ss a g e s d is se m in a te d t h ro u g h id e n tif ie d d e liv e ry s tr a te g ie s 3 .1 .7 R e p o rt is c o m p le te d a n d d is se m in a te d 3 .1 .8 A d vo ca cy s tr a te g y is d e ve lo p e d R e se a rc h r e p o rt A ct iv ity r e p o rt s C u rr ic u lu m d o cu m e n t p u b lis h e d R e p o rt s F a ci lit y su rv e y (G A V I H S S ) D o cu m e n ta tio n Im p le m e n tin g p a rt n e r re p o rt s P u b lis h e d m a te ri a ls D o cu m e n ta tio n P u b lis h e d r e p o rt P u b lis h e d s tr a te g y F in d in g s a re r e lia b le C o u n se llo rs a re m o tiv a te d to p ro vi d e s u p p o rt H e a lth f a ci lit y st a ff a re m o tiv a te d t o p ro vi d e co u n se lli n g R e so u rc e s a va ila b le S e cu ri ty s itu a tio n a llo w s C o m m u n ity g ro u p s e tc w ill in g t o e n g a g e T a rg e t a u d ie n ce r e ce p tiv e to n e w m e ss a g e s e ve n if co n tr a ry t o t ra d iti o n a l b e lie fs P ri va te s e ct o r w ill in g t o e n g a g e , re ce p tiv e t o 28 tr a d e rs /im p o rt e rs o f b re a st m ilk s u b st itu te s 3 .1 .9 C o n d u ct s e n si tis a tio n o n t h e p ri n ci p le s a n d a im s o f In te rn a tio n a l c o d e o f M a rk e tin g o f B re a st m ilk S u b st itu te s w ith v ie w t o a ll p a rt ie s a d o p tin g a n d s ig n in g 3 .1 .1 0 D e ve lo p a r o a d m a p f o r th e d ra ft in g a n d im p le m e n ta tio n o f a lo ca l C o d e o f M a rk e tin g o f B re a st m ilk s u b st itu te s 3 .2 .1 C o n d u ct f o rm a tiv e r e se a rc h t o a ss e ss e n a b lin g fa ct o rs a n d b a rr ie rs t o o p tim a l co m p le m e n ta ry fe e d in g p ra ct ic e s 3 .2 .2 D e ve lo p a n d im p le m e n t a t ra in in g p la n a n d cu rr ic u la f o r co m m u n ity b a se d w o rk e rs a n d h e a lth f a ci lit y st a ff ( in te g ra te in to e xi st in g cu rr ic u la f o r C H W & M C H & T B A ) 3 .2 .3 D e ve lo p k e y re g io n s p e ci fic m e ss a g e s a n d re ci p e s fo r o p tim a l c o m p le m e n ta ry f e e d in g p ra ct ic e s a n d in te g ra te w ith s im p le m e ss a g e s o n f o o d s a fe ty a n d g o o d h yg ie n e p ra ct ic e s 3 .2 .4 D is se m in a te m e ss a g e s th ro u g h e ff e ct iv e d e liv e ry m e ch a n is m s in cl u d in g in d iv id u a l co u n se lli n g , sc h o o ls , re lig io u s/ co m m u n ity g ro u p s & le a d e rs a n d m a ss m e d ia c h a n n e ls 3 .3 .1 C o n d u ct f o rm a tiv e r e se a rc h o n i d e n tif ic a tio n o f lo ca lly a va ila b le n u tr ie n t d e n se fo o d s a n d h a b its , ta b o o s, p ra ct ic e s th a t in flu e n ce th e ir co n su m p tio n 3 .3 .2 B a se d o n a b o ve , d e ve lo p k e y m e ss a g e s a n d re ci p e s to p ro m o te c o n su m p tio n o f a p p ro p ri a te 3 .1 .9 S e n si tis a tio n is c o n d u ct e d 3 .1 .1 0 R o a d m a p is d e ve lo p e d 3 .2 .1 E n a b lin g f a ct o rs a n d b a rr ie rs a re id e n tif ie d 3 .2 .2 a C u rr ic u la & t ra in in g p la n is d e ve lo p e d 3 .2 .2 b N u m b e r o f h e a lth w o rk e rs t ra in e d in o p tim a l c o m p le m e n ta ry f e e d in g p ra ct ic e s 3 .2 .3 M e ss a g e s a n d r e ci p e s a re d e ve lo p e d 3 .2 .4 B C C im p le m e n te d 3 .3 .1 R e se a rc h c o n d u ct e d & f in d in g s d is se m in a te d 3 .3 .2 K e y m e ss a g e s d e ve lo p e d & d is se m in a te d Im p le m e n tin g p a rt n e r re p o rt s P u b lis h e d r o a d m a p R e se a rc h r e p o rt R e p o rt s D a ta b a se o n t ra in e d h e a lth w o rk e rs R e p o rt s A ct iv ity r e p o rt s R e se a rc h r e p o rt A ct iv ity r e p o rt s a d vo ca cy F in d in g s a re r e lia b le H e a lth s ta ff a re m o tiv a te d t o p ro vi d e c o u n se lli n g T a rg e t a u d ie n ce r e ce p tiv e to n e w m e ss a g e s e ve n if co n tr a ry t o t ra d iti o n a l b e lie fs In st itu tio n s in t h e m e ch a n is m a re w ill in g t o a cc e p t n e w in n o va tio n C o m m u n ity w ill in g t o s h a re kn o w le d g e a n d in fo rm a tio n T a rg e t a u d ie n ce r e ce p tiv e to n e w m e ss a g e s e ve n if 29 n u tr ie n t d e n se fo o d s, in cl u d in g se a fo o d a n d o ff a l, a n d d is se m in a te to g e n e ra l p o p u la tio n th ro u g h a p p ro p ri a te c o m m u n ity b a se d d e liv e ry ch a n n e ls 3 .3 .3 L in k w ith a g ri cu ltu re /li ve lih o o d s se ct o r to p ro m o te p ro d u ct io n & u til is a tio n o f lo ca lly a va ila b le n u tr ie n t d e n se f o o d s 3 .3 .4 L in k w ith a g ri cu ltu re /li ve lih o o d s se ct o r to in cr e a se u n d e rs ta n d in g a n d u se o f a p p ro p ri a te fo o d p re se rv a tio n t e ch n iq u e s e sp e ci a lly o f m ilk a n d m ilk p ro d u ct s 3 .4 .1 C o n d u ct f o rm a tiv e r e se a rc h t o id e n tif y co m m o n p ra ct ic e s th a t ca u se s ig n ifi ca n t in h ib iti o n o f m ic ro n u tr ie n t a b so rp tio n f ro m d ie t 3 .4 .2 D e ve lo p k e y m e ss a g e s a im e d a t re d u ci n g th e se p ra ct ic e s a n d d is se m in a te t o g e n e ra l p o p u la tio n t h ro u g h a p p ro p ri a te c o m m u n ity b a se d d e liv e ry c h a n n e ls 3 .5 .1 D e ve lo p a n d im p le m e n t tr a in in g p la n a n d cu rr ic u la o n n u tr iti o n c o u n se lli n g s ki lls f o r p re g n a n t a n d la ct a tin g w o m e n f o r C H W & M C H st a ff 3 .5 .2 M C H s ta ff p ro vi d e a p p ro p ri a te n u tr iti o n co u n se lli n g ( in cl u d in g lo ca l f o o d d e m o n st ra tio n s) a t a n te n a ta l a n d p o st n a ta l vi si ts 3 .5 .3 C o n d u ct t ri a ls t o id e n tif y in n o va tiv e p o p u la tio n b a se d d e liv e ry m e ch a n is m f o r n u tr iti o n co u n se lli n g f o r p re g n a n t a n d la ct a tin g w o m e n 3 .5 .4 E st a b lis h p o p u la tio n b a se d d e liv e ry m e ch a n is m ( in cl u d in g m o n ito ri n g s ys te m ), p ro vi d in g t ra in in g , te ch n ic a l & m a te ri a l s u p p o rt 3 .3 .3 N u m b e r o f in te r se ct o r te ch n ic a l co n su lta tio n s h e ld 3 .3 .4 F o ru m o n f o o d p re se rv a tio n te ch n iq u e s e st a b lis h e d 3 .4 .1 R e se a rc h c o n d u ct e d & f in d in g s d is se m in a te d 3 .4 .2 K e y m e ss a g e s d e ve lo p e d & d is se m in a te d 3 .5 .1 C u rr ic u la & t ra in in g p la n d e ve lo p e d & im p le m e n te d 3 .5 .2 8 0 % p re g n a n t a n d la ct a tin g w o m e n a tt e n d in g M C H r e ce iv e n u tr iti o n c o u n se lli n g 3 .5 .3 T ri a ls c o n d u ct e d & d e liv e ry m e ch a n is m id e n tif ie d 3 .5 .4 D e liv e ry m e ch a n is m e st a b lis h e d R e p o rt s R e p o rt s R e se a rc h r e p o rt d o cu m e n ta tio n D a ta b a se o n t ra in e d p e rs o n n e l H M IS T ri a l r e p o rt s A ct iv ity r e p o rt s co n tr a ry t o t ra d iti o n a l b e lie fs A g ri cu ltu re a n d li ve lih o o d s se ct o r re ce p tiv e t o co lla b o ra tio n C o m m u n ity w ill in g t o s h a re kn o w le d g e a n d in fo rm a tio n T a rg e t a u d ie n ce r e ce p tiv e to n e w m e ss a g e s e ve n if co n tr a ry t o t ra d iti o n a l b e lie fs M C H s ta ff m o tiv a te d t o p ro vi d e c o u n se lli n g P re g n a n t & la ct a tin g w o m e n re ce p tiv e t o c o u n se lli n g 30 O u tc o m e 4 P ro je ct d es cr ip ti o n In d ic at o rs S o u rc e o f ve ri fi ca ti o n A ss u m p ti o n s O ut co m e 4: Im pr ov ed a va ila bi lit y an d co ve ra ge o f m ic ro nu tr ie nt s an d de w or m in g in te rv en tio ns to th e po pu la tio n 8 In cr ea si ng tr en ds in b i a nn ua l vi ta m in A s up pl em en ta tio n in ch ild re n 6 59 m on th s, a nd de w or m in g co ve ra ge in 1 5 y ea rs , sc ho ol a ge d ch ild re n, p re gn an t ( no t 1s t t rim es te r) & la ct at in g w om en B as el in e co ve ra ge d at a fr om M ic ro nu tr ie nt s ur ve y M IC S , F S N A U s ur ve y re po rt s A cc es s to fu nc tio ni ng h ea lth s er vi ce s A cc es s to fo od s ec ur ity A cc es s to h ea lth y en vi ro nm en t O ut pu ts : 4. 1 In cr ea se d av ai la bi lit y of fo rt ifi ed fo od 4. 2 Im pr ov ed a cc es s to a nd u til is at io n of m ic ro nu tr ie nt su pp le m en ts a nd f or tif ie d su pp le m en ta ry f oo d by vu ln er ab le g ro up s, i nc lu di ng u nd er f iv es , pr eg na nt an d la ct at in g w om en , th ro ug h he al th s er vi ce s an d co m m un ity b as ed d el iv er y st ra te gi es 4. 1a 2 0% c er ea ls p ro vi de d as hu m an ita ria n as si st an ce a re fo rt ifi ed b y en d of th ird y ea r 4. 1b 2 0% in cr ea se in a va ila bi lit y of fo rt ifi ed fo od ( no n hu m an ita ria n) b y en d of th ird y ea r 4. 2a a t l ea st 8 0% a cc es si bl e ch ild re n 6 59 m on th s re ce iv ed bi a nn ua l V ita m in A th ro ug h C H D 4. 2b 9 0% c hi ld re n 6 to 5 9 m on th s in nu tr iti on p ro gr am m es r ec ei ve d vi ta m in A d os e 4. 2c 8 0 % w om en a nd c hi ld re n w ho ac ce ss M C H s er vi ce s re ce iv e re co m m en de d m ul tip le m ic ro nu tr ie nt s up pl em en ta tio n 4. 2d N um be r of p re gn an t a nd la ct at in g w om en w ho r ec ei ve d m ul tip le m ic ro nu tr ie nt W F P d at a W F P d at a on im po rt s C H D r ep or ts /F S N A U nu tr iti on s ur ve y re po rt s Im pl em en tin g pa rt ne r re po rt s H M IS M IC S P ro gr am m e da ta C om m un ity w ill in g to a cc ep t f or tif ie d fo od S ec ur ity s itu at io n al lo w s ac ce ss fo r im pl em en ta tio n an d ut ili sa tio n of se rv ic es M ic ro nu tr ie nt s up pl em en ts & fo rt ifi ed su pp le m en ta ry fo od a cc ep ta bl e to ta rg et p op ul at io ns T ar ge t p op ul at io ns c om pl y w ith su pp le m en ta tio n re gi m e 31 4. 3 In cr ea se d co ve ra ge o f de w or m in g th ro ug h po pu la tio n ba se d de liv er y m e ch an is m s: a ) C hi ld H ea lth D ay s, b ) sc ho ol s, c ) M C H s er vi ce s an d d) nu tr iti on p ro gr am m e s su pp le m e nt at io n th ro ug h co m m un ity b as ed d el iv er y m e ch an is m 4. 2e 9 5% o f ta rg et ed b en ef ic ia ri es re ce iv ed f or tif ie d su pp le m en ta ry f oo d 4. 3a > 80 % a cc es si bl e ch ild re n ag ed 1 t o 5 y ea rs r ec ei vi ng de w or m in g th ro ug h C H D 4. 3b 7 0% c hi ld re n at te nd in g sc ho ol r ec ei ve d e w or m in g 4. 3c 4 0% e lig ib le p re gn an t (n ot 1 st tr im es te r) an d la ct at in g w om en a tt en di ng M C H re ce iv e de w or m in g 4. 3d 9 0% e lig ib le n ut ri tio n pr og ra m m e b en ef ic ia ri es re ce iv in g de w or m in g Im pl em en tin g pa rt ne rs re po rt s P ro gr am m e e va lu at io n da ta C H D r e p o rt s S ch oo l r ep or ts o f de w o rm in g ac tiv iti es / pr og ra m m e r ep or ts H M IS Im pl em en tin g pa rt ne r re po rt s A ct iv iti es : 4. 1. 1 F or m a f oo d fo rt ifi ca tio n su b w or ki ng g ro up o f th e nu tr iti on c lu st er , w ith d ef in ed T O R s an d m e m b e rs h ip 4. 1. 2 C om m is si on f oo d fo rt ifi ca tio n ex pe rt f or p er io d of 6 m o nt hs 4. 1. 3 B y en d of f ir st y ea r, c on du ct f ea si bi lit y st ud y of ho w f or tif ic at io n of c er ea l f lo ur s fo r hu m an ita ri an f oo d as si st an ce c an b e im pr ov ed , in cl ud in g th e de fin iti on o f ta rg et s to b e ac hi ev ed o ve r su bs eq ue nt t w o ye ar s 4. 1. 4 P ilo t pr oj ec t of in cl us io n of f or tif ie d ce re al f lo ur s in h um an ita ri an a ss is ta nc e ge ne ra l f oo d ra tio n 4. 1. 1 F oo d fo rt ifi ca tio n su b w or ki ng gr ou p is f or m ed a nd m e et s re gu la rl y 4. 1. 2 E xp er t is c om m is si on ed 4. 1. 3 F ea si bi lit y st ud y co nd uc te d & ta rg et s de fin ed 4. 1. 4 1 00 % t ar ge te d po pu la tio n re ce iv in g fo rt ifi ed c er ea l T O R s M ee tin g re po rt s R ep or t Im pl em en tin g ag en ci es re po rt s S u ita b le c a n d id a te a va ila b le S uf fic ie nt s up pl ie s an d lo gi st ic s up po rt 32 co nd uc te d fo r a sp ec ifi c ta rg et p op ul at io n de fin ed b y nu tr iti on & fo od a id c lu st er s 4. 1. 5 D ev el op a fr am ew or k an d ac tio n pl an , i nc lu di ng re gu la to ry m ec ha ni sm , f or th e fo rt ifi ca tio n of im po rt ed fo od th ro ug h en ga gi ng w ith n at io na l an d lo ca l a ut ho rit ie s an d pr iv at e se ct or 4. 1. 6 Im pl em en t a ct io n pl an fo r fo rt ifi ca tio n of im po rt ed fo od 4. 1. 7 E xp lo re th e po te nt ia l f or fo rt ifi ca tio n of lo ca l av ai la bl e fo od th ro ug h en ga gi ng w ith lo ca l a nd na tio na l a ut ho rit ie s an d pr iv at e se ct or d ur in g ye ar 1 4. 1. 8 C on du ct in ve st ig at io n in to io di ne s itu at io n in co un tr y 4. 2. 1 P ro vi de tr ai ni ng , s up pl ie s an d m on ito rin g in pu t to im pr ov e di st rib ut io n of v ita m in A su pp le m en ts to a ll ch ild re n 6 5 9 m on th s th ro ug h bi a nn ua l c hi ld h ea lth d ay s 4. 2. 2 D ev el op s im pl e S om al ia s pe ci fic s ta nd ar di se d pr ot oc ol s fo r m ic ro nu tr ie nt s up pl em en ta tio n fo r pr eg na nt & la ct at in g w om en 4. 2. 3 D ev el op a nd im pl em en t c ur ric ul a an d tr ai ni ng pl an fo r C H W a nd M C H s ta ff on m ic ro nu tr ie nt su pp le m en ta tio n 4. 2. 4 P ro vi de m ic ro nu tr ie nt s up pl em en ta tio n su pp lie s on ti m el y ba si s 4. 2. 5 M C H s ta ff pr ov id e ap pr op ria te m ic ro nu tr ie nt su pp le m en ta tio n at a nt en at al a nd p os t n at al vi si ts flo ur s in h um an ita ria n as si st an ce g en er al fo od ra tio n 4. 1. 5 F ra m ew or k, a ct io n pl an a nd re gu la to ry m ec ha ni sm de ve lo pe d 4. 1. 6 9 5% a ct io n po in ts o f p la n im pl em en te d 4. 1. 7 P ot en tia l f or lo ca l f or tif ic at io n is d ef in ed 4. 1. 8 In ve st ig at io n is c on du ct ed 4. 2. 1a > 9 0% C H D w or ke rs tr ai ne d, 4. 2. 1b > 90 % r eq ui re d su pp lie s pr ov id ed 4. 2. 1c > 95 % m on ito rin g ta rg et s m et 4. 2. 2 s ta nd ar di se d pr ot oc ol de ve lo pe d 4. 2. 3 N um be r of C H W a nd M C H st af f t ra in ed o n m ic ro nu tr ie nt su pp le m en ta tio n 4. 2. 4 N um be r of d ay s st oc k ou ts 4. 2. 5 8 0% p re gn an t a nd la ct at in g w om en a tte nd in g M C H re ce iv in g m ic ro nu tr ie nt su pp le m en ta tio n D oc um en ta tio n R ev ie w o f a ct iv iti es R ep or t D oc um en ta tio n C H D e va lu at io n re po rt s D oc um en ta tio n N ew d at ab as e on tr ai ni ng re ce iv ed b y he al th w or ke rs H M IS H M IS W ill in gn es s of p riv at e se ct or to e ng ag e an d co o pe ra te F in an ci al a nd m at er ia l r es ou rc es av ai la bl e In te re st a nd s up po rt in fo od fo rt ifi ca tio n fr om lo ca l a nd n at io na l a ut ho rit ie s C H D w or ke rs m ot iv at ed H ea lth w or ke rs m ot iv at ed to p ro vi de m ic ro nu tr ie nt s up pl em en ta tio n S uf fic ie nt r es ou rc es & e ffi ci en t l og is tic al su pp or t a va ila bl e In st itu tio ns /g ro up s id en tif ie d w ill in g an d ac ce pt in g of in vo lv em en t 33 4. 2. 6 C on du ct tr ia ls to id en tif y in no va tiv e po pu la tio n ba se d de liv er y m ec ha ni sm s fo r m ul tip le m ic ro nu tr ie nt s up pl em en ta tio n to w om en o f re pr od uc tiv e ag e 4. 2. 7 B as ed o n tr ia ls , s ca le u p po pu la tio n ba se d de liv er y m ec ha ni sm fo r m ul tip le m ic ro nu tr ie nt su pp le m en ta tio n, in cl ud in g pr ot oc ol de ve lo pm en t, tr ai ni ng , s up pl ie s an d m on ito rin g sy st em 4. 2. 8 C on du ct fe as ib ili ty s tu dy o f h om e fo rt ifi ca tio n pr od uc ts , d ef in in g ta rg et s an d ac tio n pl an fo r su bs eq ue nt im pl em en ta tio n 4. 2. 9 Im pl em en t a ct io n pl an o n ho m e fo rt ifi ca tio n pr od uc ts a cc or di ng to fe as ib ili ty s tu dy re co m m en da tio ns 4. 2. 10 D is tr ib ut e fo rt ifi ed s up pl em en ta ry fo od s to vu ln er ab le g ro up s in s el ec te d hi gh r is k ar ea s as d ef in ed b y nu tr iti on c lu st er 4. 3. 1 P ro vi de t ra in in g, s up pl ie s an d m on ito rin g in pu t fo r de w or m in g to b i an nu al C H D s & n ut rit io n pr og ra m m es 4. 3. 2 D ev el op s im pl e, S om al i s pe ci fic p ro to co l f or de w or m in g in s ch oo ls , i nc lu di ng s ys te m fo r m on ito rin g & e va lu at io n 4. 3. 3 P ro vi de te ch ni ca l ( W H O ) & lo gi st ic al ( W F P ) su pp or t t o sc ho ol s de w or m in g pr og ra m m e 4. 3. 4 D ev el op s im pl e pr ot oc ol fo r de w or m in g of pr eg na nt & la ct at in g w om en a nd c hi ld re n 1 5 ye ar s at M C H fa ci lit ie s & H ea th p os ts , a im ed a t 4. 2. 6 P op ul at io n ba se d de liv er y m ec ha ni sm id en tif ie d by e nd of p ha se 1 4. 2. 7 D el iv er y m ec ha ni sm fo r m ul tip le m ic ro nu tr ie nt su pp le m en ta tio n is es ta bl is he d in s el ec te d ar ea s, b y en d ph as e 2 4. 2. 8 F ea si bi lit y st ud y is co nd uc te d, ta rg et s se t, ac tio n pl an d ef in ed , b y en d of p ha se 1 4. 2. 9 A ct io n pl an im pl em en te d in se le ct ed a re as , b y en d of ph as e 2 4. 2. 10 7 5% ta rg et ed b en ef ic ia rie s re ac he d 4. 3. 1a 9 5% C H D w or ke rs tr ai ne d, 4. 3. 1b 9 5% r eq ui re d su pp lie s pr ov id ed 4. 3. 1c 9 5% m on ito rin g ta rg et s m et 4. 3. 2 a) P ro to co l i s de ve lo pe d b) in cr ea si ng tr en ds in x % s ch oo ls im pl em en tin g pr ot oc ol 9 4. 3. 3 90 % ta rg et ed s ch oo ls r ec ei ve de fin ed s up po rt 4. 3. 4a P ro to co l i s de ve lo pe d 4. 3. 4b in cr ea si ng tr en ds in x % he al th fa ci lit ie s im pl em en tin g A ct iv ity r ep or ts T ria l r ep or ts Im pl em en tin g ag en ci es re po rt s S tu dy r ep or t A ct iv ity r ep or ts Im pl em en tin g ag en ci es re po rt s C H D & n ut rit io n pr og ra m m e re po rt s D oc um en ta tio n S ch oo l, W H O , W F P re po rt s D oc um en ta tio n F ac ili ty s ur ve y da ta S uf fic ie nt r es ou rc es & e ffi ci en t l og is tic al su pp or t a va ila bl e T ar ge te d be ne fic ia rie s w ill in g to u se ne w m ec ha ni sm H om e fo rt ifi ca tio n pr od uc ts a cc ep ta bl e to b en ef ic ia rie s T ar ge te d be ne fic ia rie s us e su pp le m en ta ry fo od s as in st ru ct ed C H D & n ut rit io n pr og ra m m e w or ke rs m ot iv at ed to p ro vi de d ew or m in g S ch oo ls r ec ep tiv e an d w ill in g to im pl em en t d ew or m in g H ea lth s ta ff m ot iv at ed to im pl em en t pr ot oc ol S uf fic ie nt s up pl ie s an d ef fic ie nt lo gi st ic al s up po rt 34 re du ci ng m is se d op po rt un iti es 4. 3. 5 P ro vi de tr ai ni ng & ti m el y su pp lie s to C H W & M C H s ta ff fo r ef fe ct iv e im pl em en ta tio n of de w or m in g pr ot oc ol de w or m in g pr ot oc ol 10 4. 3. 5a N um be r of h ea lth s ta ff tr ai ne d an d ac tiv e on d ew or m in g 4. 3. 5b N um be r of d ay s of s to ck o ut s of d ew or m in g dr ug s N ew d at ab as e on tr ai ni ng of h ea lth w or ke rs H M IS S up pl y da ta 35 O u tc o m e 5 P ro je ct d es cr ip ti o n In d ic at o rs S o u rc e o f ve ri fi ca ti o n A ss u m p ti o n s O u tc o m e 5 : Im p ro ve d m a in st re a m in g o f n u tr iti o n a s a k e y co m p o n e n t o f h e a lth a n d o th e r re le va n t se ct o rs 7 0 % h e a lth , W A S H , liv e lih o o d , e d u ca tio n a n d f o o d a id C A P p ro je ct s in cl u d e n u tr iti o n in d ic a to rs 5 0 % o f h e a lth , W A S H , L iv e lih o o d , e d u ca tio n s e ct o r p ro je ct s in cl u d e n u tr iti o n a ct iv iti e s N u tr iti o n a ct iv iti e s/ o u tc o m e s a re in cl u d e d in U N S A S C A P r e vi e w 3 W s o f se ct o r cl u st e rs a n d w o rk in g g ro u p s U N S A S r e vi e w O u tp u ts : 5 .1 N u tr iti o n is e ff e ct iv e ly in co rp o ra te d in to t h e p o lic ie s, st ra te g ie s, a ct iv iti e s, d e liv e ry m e ch a n is m s a n d o u tc o m e s o f h e a lth s e ct o r 5 .1 a n u m b e r o f re le va n t h e a lth se ct o r p o lic ie s e tc in cl u d in g n u tr iti o n in d ic a to rs 5 .1 b 6 0 % 11 w o m e n a n d c h ild re n a tt e n d in g M C H s e rv ic e s w h o re ce iv e a p p ro p ri a te n u tr iti o n sc re e n in g , n u tr iti o n c o u n se lli n g & m ic ro n u tr ie n t tr e a tm e n t o r su p p le m e n ta tio n b y e n d o f fir st p h a se , in cr e a si n g t o 8 0 % b y e n d o f p h a se 2 5 .1 c > 8 0 % t a rg e te d b e n e fic ia ri e s o f C H D r e ce iv in g v ita m in A , n u tr iti o n sc re e n in g & d e w o rm in g 5 .1 d N u tr iti o n in te rv e n tio n s a re in cl u d e d a s co re c o m p o n e n t in R e vi e w o f p o lic y, st ra te g y a ct iv ity d o cu m e n ts H M IS C H D e va lu a tio n r e p o rt s R e vi e w o f p o lic ie s a n d p ro g ra m m e s W ill in g n e ss o f o th e r se ct o rs t o co lla b o ra te 36 5 .2 N u tr iti o n i s in te g ra te d i n to t h e p o lic ie s, s tr a te g ie s, a ct iv iti e s, d e liv e ry m e ch a n is m s a n d o u tc o m e s o f W A S H , liv e lih o o d s, e d u ca tio n a n d f o o d a id s e ct o rs m a n a g e m e n t o f re le va n t co m m u n ic a b le a n d n o n co m m u n ic a b le d is e a se s e g T B , H IV , m a la ri a , m e n ta l h e a lth 5 .2 a W A S H 5 0 % o f re le va n t W A S H in te rv e n tio n s in cl u d e n u tr iti o n in d ic a to rs a s m e a su re o f im p a ct 7 5 % n u tr iti o n p ro g ra m m e s d e liv e ri n g g o o d h yg ie n e p ro m o tio n a ct iv iti e s 5 .2 b A g ri cu ltu re /L iv e lih o o d s 7 0 % r e le va n t p ro je ct s in co rp o ra tin g n u tr iti o n in d ic a to rs a s o u tc o m e in d ic a to rs , 7 0 % r e le va n t p ro je ct s u se n u tr iti o n st a tu s fo r ta rg e tin g in te rv e n tio n s 7 0 % r e le va n t p ro je ct s in cl u d e n u tr iti o n e d u ca tio n a s a s u p p o rt in g a ct iv ity 5 .2 c E d u ca tio n 7 0 % s ch o o ls p ro vi d e n u tr iti o n e d u ca tio n a s p a rt o f re g u la r cu rr ic u lu m R e vi e w o f p o lic ie s a n d p ro je ct s R e vi e w o f p o lic ie s a n d p ro je ct s R e vi e w o f cu rr ic u la S ch o o l r e p o rt s W ill in g n e ss o f h e a lth s e ct o r to co lla b o ra te S u ff ic ie n t re so u rc e s a va ila b le A ct iv iti e s: 5 .1 .1 F o st e r im p ro ve d in te rs e ct o ra l co lla b o ra tio n & d e fin e p ri o ri ty a re a s fo r p a rt n e rs h ip 5 .1 .1 a n u m b e r o f in te rs e ct o ra l co n su lta tio n m e e tin g s h e ld 5 .1 .1 b x % a tt e n d a n ce a t se ct o r cl u st e r m e e tin g s1 2 M e e tin g r e p o rt s W ill in g n e ss o f o th e r se ct o rs t o co lla b o ra te 37 5. 1. 2 E st ab lis h m ec ha ni sm fo r te ch ni ca l nu tr iti on in pu t i nt o re le va nt m ee tin gs , r ev ie w s 5. 1. 3 P ro vi de ne ce ss ar y in pu ts (f un di ng , tr ai ni ng , su pp lie s, m on ito rin g) to im pr ov e qu al ity of nu tr iti on se rv ic es de liv er ed th ro ug h C H D s, ac co rd in g to d ef in ed ta rg et s 5. 1. 4 P ro vi de ne ce ss ar y in pu ts to im pr ov e qu al ity an d co ve ra ge of nu tr iti on se rv ic es de liv er ed th ro ug h he al th f ac ili tie s (s ta nd ar di se d gu id el in es an d pr ot oc ol s fo r nu tr iti on ac tiv iti es , su pp lie s, co m pr eh en si ve tr ai ni ng fo r he al th fa ci lit y st af f) 5. 1. 5 C on du ct m ap pi ng o f ar ea s w ith p oo r ac ce ss t o he al th s er vi ce s 5. 1. 6 A dv oc at e in lo ca tio ns w he re av ai la bi lit y of he al th se rv ic es is a lim iti ng fa ct or fo r op tim al nu tr iti on 5. 1. 7 C on du ct se ns iti sa tio n on nu tr iti on as de te rm in an t of h ea lth a nd d ev el op m en t am on g lin e m in is tr ie s an d ad vo ca te fo r in cl us io n of nu tr iti on in te rv en tio ns as co re co m po ne nt of pu bl ic s er vi ce s 5. 2. 1 F os te r in te rs ec to ra l co lla bo ra tio n an d de fin e pr io rit y ar ea s fo r pa rt ne rs hi p w ith e ac h se ct or (e g ag ri cu ltu re /li ve lih oo ds im pr ov in g di et ar y di ve rs ity , W A S H : B C C in te gr at in g pr om ot io n of op tim al n ut ri tio n an d go od h yg ie ne p ra ct ic es , ed uc at io n i nt eg ra tin g nu tr iti on e du ca tio n in to sc ho ol c ur ri cu la ) 5. 1. 2 m ec ha ni sm e st ab lis he d 5. 1. 3 90 % in pu ts p ro vi de d, ac co rd in g to d ef in ed ta rg et s 5. 1. 4a x % h ea lth fa ci lit ie s us in g st an da rd is ed gu id el in es /p ro to co ls 13 5. 1. 4b N um be r of d ay s st oc k ou ts o f nu tr iti on s up pl ie s 5. 1. 4c x % h ea lth fa ci lit y st af f re ce iv ed n ut rit io n tr ai ni ng 14 5. 1. 5 M ap pi ng c on du ct ed a nd do cu m en te d 5. 1. 6 N um be r of a dv oc ac y m ee tin gs he ld 5. 1. 7 N um be r of m ee tin gs h el d to di sc us s nu tr iti on w ith li ne m in is tr ie s 5. 2. 1a n um be r of in te rs ec to ra l co ns ul ta tio n m ee tin gs h el d, 5. 2. 1b x % a tt en da nc e at s ec to r cl us te r m ee tin gs 15 5. 2. 1c P rio rit y ar ea s de fin ed R ep or ts C H D e va lu at io n re po rt s H M IS F ac ili ty b as ed s ur ve y H M IS S up pl y da ta D at ab as e on tr ai ne d he al th p er so nn el R ep or ts M ee tin g re po rt s M ee tin g re po rt s R ep or ts S uf fic ie nt s up pl ie s & lo gi st ic al su pp or t t o im pl em en t C H D s ef fe ct iv el y H ea lth fa ci lit y st af f m ot iv at ed to im pl em en t n ut rit io n ac tiv iti es S ec to r op en to a dv oc ac y S uf fic ie nt r es ou rc es a va ila bl e W ill in gn es s of o th er s ec to rs to co lla bo ra te 38 5. 2. 2 E st ab lis h a m ec ha ni sm f or t ec hn ic al n ut rit io n in pu t i nt o re le va nt p ro ce ss 5. 2. 3 P ro vi de t ec hn ic al i np ut , tr ai ni ng a nd m at er ia ls fo r im pr ov in g nu tr iti on c om po ne nt o f re le va nt se ct or pr og ra m m in g, ac co rd in g to ag re ed ta rg et s 5. 2. 4 C on du ct m ap pi ng o f ar ea s w ith p oo r ac ce ss t o W A S H / ag ric ul tu re /li ve lih oo ds /e du ca tio n /fo od ai d se rv ic es 5. 2. 5 A dv oc at e in lo ca tio ns w he re av ai la bi lit y of W A S H /a gr ic ul tu re /li ve lih oo ds /e du ca tio n/ fo od ai d se rv ic es a re a l im iti ng f ac to r fo r op tim al nu tr iti on 5. 2. 2 M ec ha ni sm e st ab lis he d 5. 2. 3a N um be r of te ch ni ca l co ns ul ta tio ns h el d 5. 2. 3b > 90 % a gr ee d m at er ia ls su pp lie d 5. 2. 3c 9 0% a gr ee d tr ai ni ng s he ld 5. 2. 4 M ap pi ng c on du ct ed 5. 2. 5 N um be r of a dv oc ac y m ee tin gs he ld R ep or t C on su lta tio n re po rt s P ro gr am m e re po rt s P ro gr am m e re po rt s D oc um en ta tio n M ee tin g re po rt s 39 O ut co m e 6 P ro je ct d es cr ip tio n In di ca to rs S ou rc e of v er if ic at io n A ss um pt io ns O ut co m e 6: Im pr ov ed c ap ac ity a nd m ea ns in c ou nt ry to d el iv er es se nt ia l n ut rit io n se rv ic es F ee di ng p ro gr am m e pe rf or m an ce in di ca to rs a s a m ea su re o f c ap ac ity of L N G O s to d el iv er tr ea tm en t In cr ea si ng tr en d in n um be r of M oH pe rs on ne l t ra in ed in n ut rit io n In cr ea si ng tr en d in n um be r he al th fa ci lit ie s w ith p er so nn el tr ai ne d in nu tr iti on A ct iv iti es o f l oc al e st ab lis he d st ru ct ur e – de ve lo p se t o f pe rf or m an ce in di ca to rs a s pa rt o f T O R s U N IC E F d at ab as e M oH r ep or ts D at ab as e on h ea lth w or ke rs a nd tr ai ni ng re ce iv ed A ct iv ity r ep or ts S ec ur ity s itu at io n al lo w s de liv er y of s er vi ce s O ut pu ts : 6. 1 A t w o ye ar n ut rit io n se ct or c ap ac ity d ev el op m en t st ra te gy a nd p la n of a ct io n is d ev el op ed jo in tly w ith lo ca l a ut ho rit ie s by th e en d of 2 01 1 6. 2 C ap ac ity de ve lo pm en t an d tr ai ni ng ac tiv iti es ar e im pl em en te d ac co rd in g to p la n of a ct io n 6. 3 R eg io na l tr ai ni ng a nd m en to rin g ce lls a re f or m ed by th e en d of 2 01 1. 6. 4 In te rn at io na lly r ec og ni se d tr ai ni ng g ui de lin es a nd pr ot oc ol s ar e ad ap te d to th e S om al i c on te xt 6. 5 A n en ab lin g en vi ro nm en t fo r al l st ak eh ol de rs to 6. 1 S tr at eg y an d ac tio n pl an is de ve lo pe d 6. 2 x% o f a ct iv iti es d ef in ed in a ct io n pl an a re im pl em en te d1 6 6. 3 C el ls a re e st ab lis he d 6. 4a 9 0% o f r el ev an t g ui de lin es a nd pr ot oc ol s ad ap te d to S om al i co nt ex t 6. 4b 8 0% p ar tn er s us in g ad ap te d gu id el in es b y en d ph as e 2 R ep or ts P ub lis he d st ra te gy R ep or ts R ev ie w o f d oc um en ts P ar tn er s re po rt s S ta ke ho ld er r ep or ts H ea lth a ut ho rit ie s, li ne m in is tr ie s ar e su pp or tiv e an d pr ov id e ne ce ss ar y co nd iti on s fo r im pl em en ta tio n R es ou rc es fo r ca pa ci ty de ve lo pm en t s tr at eg y ar e fo rt hc om in g N ew tr ai ni ng & m en to rin g ce lls ac ce pt ed a nd g iv en s uf fic ie nt m an da te im p le m e n t q u a lit y n u tr iti o n p ro g ra m m e s is c re a te d a n d su st a in e d in co lla b o ra tio n w ith th e lo ca l a u th o ri tie s 6 .5 9 0 % o f ta rg e te d s ta ke h o ld e rs re ce iv in g n e ce ss a ry e q u ip m e n t, m a te ri a ls a n d re so u rc e s, a cc o rd in g t o a st a n d a rd iz e d a n d a cc e p te d li st of m a te ri al s ie c om pu te r, in te rn e t co n n e ct io n , p h o to co p ie r e tc . a n d a g e n ci e s su p p ly d a ta S u ff ic ie n t re so u rc e s a va ila b le A ct iv iti es : 6 .1 .1 E st a b lis h st ra te g y d e ve lo p m e n t w o rk in g g ro u p w ith d e fin e d T O R s 6 .1 .2 Id e n tif y sc o p e o f st ra te g y 6 .1 .3 E n su re m u lti f a ce te d a p p ro a ch t o d e ve lo p m e n t o f te ch n ic a l sk ill s – h a n d s o n t ra in in g , w o rk sh o p s, d is ta n ce le a rn in g o p p o rt u n iti e s, re g io n a l vi si ts a n d w o rk sh o p s, a p p ro p ri a te n u tr iti o n tr a in in g in te g ra te d in to e xi st in g p re s e rv ic e tr a in in g cu rr ic u la 6 .1 .4 C re a te lin ks w ith re g io n a l tr a in in g /m e n to ri n g ce lls , in te rn a tio n a l a ca d e m ic /t ra in in g in st itu tio n s 6 .1 .5 A d vo ca te f o r a n d id e n tif y fu n d in g o f st ra te g y 6 .2 .1 P ro vi d e n e ce ss a ry su p p o rt a n d in p u ts fo r im p le m e n ta tio n o f p la n o f a ct io n 6 .3 .1 D e fin e s co p e a n d r o le o f re g io n a l tr a in in g a n d m e n to ri n g c e lls 6 .3 .2 E st a b lis h le a d e rs h ip a n d m e m b e rs h ip 6 .3 .3 Id e n tif y g a p s a n d t ra in in g n e e d s 6 .1 .1 W o rk in g g ro u p e st a b lis h e d & T O R s 6 .1 .2 S co p e d e fin e d 6 .1 .3 M u lti f a ce te d a p p ro a ch a d o p te d 6 .1 .4 n u m b e r o f lin ks e st a b lis h e d 6 .1 .5 x % f u n d in g id e n tif ie d 17 6 .2 .1 9 0 % in p u ts p ro vi d e d a cc o rd in g t o p la n o f a ct io n 6 .3 .1 T O R s d e fin e d & a g re e d 6 .3 .2 L e a d e rs h ip a n d m e m b e rs h ip e n d o rs e d 6 .3 .3 G a p s a n d t ra in in g n e e d s id en tif ie d D o cu m e n ta tio n D o cu m e n ta tio n R e vi e w o f st ra te g y D o cu m e n ta tio n D o cu m e n ta tio n D o cu m e n ta tio n C e ll re po rt C e ll re po rt D o cu m e n ta tio n A ct iv ity r e p o rt s W o rk in g g ro u p m e m b e rs m o tiv a te d D o n o rs a re r e ce p tiv e S u ff ic ie n t re so u rc e s a va ila b le H e a lth a u th o ri tie s, li n e m in is tr ie s a re s u p p o rt iv e a n d p ro vi d e n e ce ss a ry c o n d iti o n s fo r e st a b lis h m e n t o f ce lls P a rt n e rs /a g e n ci e s w ill in g t o 40 41 6. 3. 4 D ev el op an d im pl em en t tr ai ni ng pl an an d cu rr ic ul a 6. 4. 1 C on st ru ct an in ve nt or y of in te rn at io na lly re co gn is ed tr ai ni ng g ui de lin es a nd p ro to co ls 6. 4. 2 A da pt an d tr an sl at e th e m os t re le va nt gu id el in es & p ro to co ls to th e S om al i c on te xt 6. 5. 1 P ro vi de ne ce ss ar y tr ai ni ng , eq ui pm en t, m at er ia ls an d re so ur ce s to pa rt ne rs im pl em en tin g nu tr iti on ac tiv iti es , in cl ud in g M oH , lin e m in is tr ie s, L N G O s an d co m m un ity in st itu tio ns to en ab le th em to im pl em en t nu tr iti on in te rv en tio ns ac co rd in g to st an da rd is ed g ui de lin es 6. 3. 4a c ur ric ul a de ve lo pe d by e nd ph as e 1 6. 3. 4b 8 0% tr ai ni ng p la n im pl em en te d by e nd p ha se 2 6. 4. 1 in ve nt or y co m pl ie d 6. 4. 2 90 % r el ev an t g ui de lin es & pr ot oc ol s ad ap te d & tr an sl at ed 6. 5. 1 90 % r es ou rc es p ro vi de d ac co rd in g to g ui de lin es R ep or t R ev ie w o f d oc um en ts S up pl y da ta ac ce pt a nd s up po rt th e co nc ep t o f tr ai ni ng a nd m en to rin g ce lls A da pt at io ns a re a cc ep ta bl e an d ad op te d by a ge nc ie s Im pl em en tin g pa rt ne r st af f m ot iv at ed to im pl em en t a ct iv iti es 1 A d at ab as e of a ll he al th c ar e pr ov id er s an d th e tr ai ni ng th ey h av e re ce iv ed is c ur re nt ly b ei ng d ev el op ed 2 If in cl ud ed in th e ne w M A M g ui de lin es 3 % to b e co nf ir m ed 4 % to b e co nf ir m ed 5 R ef er en ce M ic ro nu tr ie nt s ur ve y 20 09 6 R ef er en ce M IC S 20 06 ( re vi se a ft er M IC S 20 10 ) 7 R ef er en ce M ic ro nu tr ie nt S ur ve y 20 09 8 Id ea lly o ut co m e in di ca to r w ou ld b e im pr ov ed m ic ro nu tr ie nt s ta tu s of p op ul at io n, r ed uc ed p re va le nc e of a na em ia , v ita m in A & io di ne d ef ic ie nc y bu t 3 y ea rs to o sh or t t o m ea su re s ig ni fi ca nt c ha ng es & a s ye t n o pl an f or r ep ea t m ic ro nu tr ie nt s ur ve y 9 % to b e co nf ir m ed 10 % to b e co nf ir m ed 11 B as ed o n E PH S fo r So m al ia 2 00 8 12 % to b e co nf ir m ed 13 % to b e co nf ir m ed 14 % to b e co nf ir m ed 15 % to b e co nf ir m ed 16 % to b e co nf ir m ed 17 % to b e co nf ir m ed 42 CONTENTS 2.2 Chronic malnutrition. 44 NUTRITION SITUATION ANALYSIS ANNEX 2 43 1. Background Information Somalia is populated by a resilient and highly independent people, whose nomadic tradition evolved to survive in the harsh and arid environment of the Horn of Africa. Since the collapse of central government in 1991 and resulting civil war, there have been many efforts to restore a central government in Somalia without sustained success. In 1991 the North west zone (NWZ) declared the independent state of Somaliland. This independence has not been recognized by most other countries but Somaliland has remained at relative peace and stability since, with governing administration in the capital Hargesia. The North east Zone (NEZ) declared itself as the autonomous region of Puntland in 1998. Although governed by its administration in its capital Garowe, it pledges to participate in any Somali reconciliation and reconstruction process that attempts to establish and support a central governing entity. extreme poverty, coupled with very low basic social service coverage, has seriously affected food in every twelve dies before the age of one year while, one child in seven dies before the age of 2. Current Nutrition Situation Today, almost all Somalis are affected by the fragile security environment, large-scale population displacements, food insecurity and lack of basic social and health services, with coping mechanisms stretched to the limit as families struggle to absorb these multiple shocks. The result is alarming rates of acute malnutrition and chronic malnutrition throughout the country with some variations by zone and livelihood system. 2.1 Acute malnutrition According to the most recent analysis from FSNAU, the Post Deyr ‘09/10 seasonal assessment, Gu 2009. These current rates correspond to 1 in 6 (240,0001) children acutely malnutrition with a 9 fold greater risk of early death than their well nourished counterparts. The FSNAU Post Gu assessment 2009 also estimated a further 84,000 pregnant women to be acutely malnourished, a condition which leads to poor intrauterine growth, low birth weight, stunting and developmental delay and predisposes to another generation of malnourished mothers perpetuating the intergenerational cycle of malnutrition. Within the overall picture there are differences by zone and by livelihood system. Eighty one percent of the acutely malnourished children live in South and Central regions - the areas also affected most by insecurity and restricted humanitarian space. In Somaliland, rates of acute malnutrition are less critical but population density is high, meaning that in a relatively high proportion of total number of acutely malnourished children live there. This has important implications for the geographical coverage of interventions. 44 As highlighted by the Post Gu 2009 assessment and again in the more recent Post Deyr 09/10 assessment, Internally Displaced Populations (IDPs) continue to be the most nutritionally vulnerable, services and create tensions with the local communities. 2.2 Chronic malnutrition The FSNAU Post Deyr 09/10 assessment found very high rates of stunting of 22% in the South Central Somalia compared to 14% in Somaliland and 11% in Puntland. The higher rates in South administration and public services and loss of livelihoods. This compares to the relative peace and stability in Somaliland. 2.3 Trends in malnutrition- 2001 to 2008 Preliminary results from a meta analysis of FSNAU surveillance data 2001 to 2008 reveal that Critical serious levels according to WHO results highlight how unacceptably high rates of acute and chronic malnutrition are a persistent problem in Somalia. Differences in malnutrition among the livelihood zones Figure 6 shows variation in median malnutrition rates for the period 2001 to 2008 according to type and by livelihood group. the national median rate. However, riverine and agropastoralist groups had the highest median rate of wasting, stunting and underweight suggesting a higher nutritional displacement and disease outbreak. Pastoralist group had the lowest rates of stunting. This may be due to physical stature masking the actual estimate (Sadler et al 2009). Differences in malnutrition – Somaliland, Puntland and South Central Somalia Figure 2 highlights how median rates of wasting, stunting and underweight for the period 2001-2008 The meta analysis of FSNAU data from 2001 to 2008 also demonstrates how in all but one year 17.25 15.7 17.9 17.1 12.1 20.6 31.5 19.3 29.7 38.2 14.4 24.624.9 19 28 29.5 11 28.9 0 5 10 15 20 25 30 35 40 45 IDP Pastoral Agropastoral Riverine Urban Mixed % p re va le nc e Median Wasting Median stunting Median Underweight Figure 6: Trends in different types of malnutrition in Somalia by livelihood group 45 and Anthropometric Nutrition survey 2009 of stunting and wasting in South Central Somalia compared to Somaliland and of data for 2010-2008 also reveals variation by region. Gedo region is the worst affected region across the country with a and a persistently Very Critical nutrition show high median wasting rates over the period 2001-2008. 2.4 Micronutrient malnutrition Throughout Somalia the presence of risk factors for micronutrient malnutrition (poverty, poor 24% but otherwise data on the extent of the problem was limited. In 2009 a national micronutrient and anthropometric nutrition survey was conducted to address the information gap and inform appropriate responses. The national two stage cluster survey was conducted in the three zones Information was also collected regarding infant feeding and care practices and anthropometric of samples. Results of the survey demonstrated the prevalence of both nutritional anaemia and of all age groups are severe according to children, 46.6% for non pregnant women and 49.1% for pregnant women. In children aged difference in prevalence of anaemia between the zones but rural children were found to be 1.3 10.7 16.5 4.1 13.9 19.5 5.9 16.5 31.6 4 13.9 23.2 0 5 10 15 20 25 30 35 SAM GAM Stunting pr ev al en ce ( % ) NEZ NWZ SCZ Combined Figure 7: Malnutrition rates by zone, according to National Anthropometric Micronutrient Survey results 2009 Testing for Anaemia, FSNAU 46 Regarding iodine, interestingly, the survey found high urinary iodine concentrations in all groups. This indicator was not investigated in Puntland. Goitre can be due to excessive or inadequate intake of iodine. 3. Determinants of Malnutrition in Somalia for the discussion of determinants of malnutrition in Somalia. The volatile political situation and its resulting insecurity, civil unrest or outright war have led to a chronic and continuing humanitarian crisis that is at the root of the high prevalence of malnutrition in Somalia. However, even in years of relative stability and improved food production, the malnutrition rates in some regions of Somalia have remained consistently high, providing evidence for the contribution of underlying causes. 3.1 Food security (Food access and availability) Somalia is chronically food insecure. Overall, around 80% of Somali households rely on natural resource-dependent activities for their livelihood, making them highly vulnerable to environmental factors and shocks. Even in good years, Somalia is only able to produce 40% of its cereal of central government in 1991. Food security varies wildly by area, season and according to climatic, political and economic factors (openness of cross border markets and internal urban markets). Traditionally, the sedentary nutritional crisis. In comparison the pastoralists have fared best as their mobile, cattle based consumption and sale of milk and animal products for their livelihoods. Livestock milk availability population as shown by a case study from West Golis/Guban livelihood zone described in the FSNAU Post Gu 2009 assessment. This shows that once availability of milk declines eg due to loss of livestock resulting from disease outbreak and or drought conditions, rates of acute malnutrition deteriorate to very critical levels but improve again once the livestock situation recovers and availability of milk increases. As discussed in the case study this demonstrates the natural ability to recover from shocks provided that they are not recurrent and cumulative. Chronic macroeconomic shocks, such as the persistent ban of livestock export and lack of employment opportunities, affected investment in productive sectors like crop and livestock. Results of the most recently conducted FSNAU led multi-agency post deyr ‘09/10 seasonal assessment indicate some improvement in the overall food security situation in country, especially in rural areas of the south where crop and livestock production has improved following normal deyr rains. However, although the number of people estimated to be in need of emergency 47 total population), this situation still represents a widespread Humanitarian Crisis affecting 42% deliver in the context of heightened insecurity and reduced access. The deyr rains also performed poorly in pastoral regions of the north and north east and has resulted in a deepening crisis in the Hawd, Addun and Sool plateau pastoral livelihood zones, with complete loss of livestock assets, especially sheep and goats. Figure 8: UNICEF Conceptual model of causes of malnutrition (taken from Lancet series on maternal and child undernutrition 2008 Short term consequences: Mortality, morbidity, disability Household food insecurity Income poverty: employment, self employment, dwelling, assets, remittances, pensions, transfers etc Social, economic and political context Lack of capital: financial, human, physical, social and natural Inadequate care Unhealthy household environment and lack of health service Long term consequences: Adult size, intellectual ability, economic productivity, reproductive performance, metabolic and cardiovascular disease Inadequate dietary intake Disease Underlying causes Basic causes Immediate causes Maternal child undernutrition Source: Lancet Series on Maternal and Child Undernutrition, 2008. 48 At household level, indicators of food security include number of meals eaten per household per day and diet diversity or number of different food groups consumed a day. Results from the micronutrient study 2009 indicate that food security as measured by number of meals eaten per meals a day. Diversity of the diet at household level also availability. Dietary diversity is generally poor in Somalia and also relates to poor knowledge and food habits. Diets consist mainly of cereal (maize or rice) oil, sugar, seasonably variable access to milk and occasional access to meat. Vegetables and/or fruit are rarely consumed. Patterns differ for pastoralist populations contribution to the diet. According to the micronutrient study 2009, the percentage of households consuming less than four foods a day was similar across all three Vulnerability Assessment 2008), highlight there is large variation by region and livelihood zone. Overall, 28% of the population consumed less than four food groups in the seven days prior to the population were only consuming a staple, oil and sugar. 68% had seasonably variable access to and meat products was generally poor across all three zones. According to the FSNAU Post Gu Very Critical nutrition situation of this IDP group in the post Gu ‘09 assessment. Generally, urban households are found to have greater household dietary diversity, according to FSNAU data. Preliminary results from the FSNAU meta analysis 2001-2008 highlight the link between diet fewer food groups) were 1.12 times more likely (p=0.001) to be malnourished than those who Manoocher Deghati IRIN 49 3.2 Social and care environment This refers to the ‘wider social and cultural context that shapes caring behaviours within the feeding practices, good hygiene, emotional support and appropriate health related behaviours are all essential for good nutrition and health. Poor breast feeding practices Early introduction of feeds Inadequate care for women/mothers Poor complementary diets – in particular among riverine and agro pastoralists Poor hygiene practices Inappropriate home health practices during illness Delay in seeking appropriate medical care days postpartum, as colostrum However, while breastfeeding is initiated by most women and practiced well into the 1st month postpartum, breastfeeding is not exclusive. Children are given water with sugar or other liquids such as cow or goat milk. According to a study of breastfeeding and dietary habits of children in rural Somalia (Ibrahim et al 1991), there was a complete absence of and water were also given daily from micronutrient and anthropometric nutrition survey 2009 found rates of exclusive breastfeeding availability of safe water and the poor development of the child immune system, the likelihood of introducing water borne infections is high. Rates of exclusive breastfeeding were lowest in micronutrient and anthropometric nutrition survey 2009, 60.8% of children aged 12-16 months levels of breastfeeding in Somalia include lack of knowledge of the importance of the practice, vigorous advertising of infant formulas and the persistence of inaccurate information and myths around breastfeeding. The reasons for apparent better breast feeding practices in Somaliland are worth further investigation and may provide lessons learned to be applied in Puntland and South Central Somalia. Figure 9: Breast feeding initiation One indicator of this is the change in frequency with which foods (breastfeeding and/or other foods) are offered during diarrhoea compared to when the child is healthy. According to results 9.6% were offered feeding less that normal, same as normal and more that normal respectively or withdrawn from feeding completely. Reduced feeding as well as withdrawal during diarrhoea can reduce the chances of full recovery and is an important risk factor for developing severe malnutrition. Practices were found to be particularly poor in Puntland, where no children were was withdrawn completely during diarrhoea. Often the care of children is closely linked with cultural and gender issues. In Somali society, women have a progressively stronger role to play in raising children, managing the household and earning income. However, male heads of household continue to make the main decisions over use of time and resources. Generally there and although they may exercise greater power over health seeking behaviour for their children, they lack decision-making power over their own health. In general, women have far lower levels of education and lower access and utilisation of health particularly for rural women. All these factors adversely affect the social and care environment of women and children and therefore their survival and nutritional status. is one of the highest in the region and corresponds to a lifetime risk of 1 maternal death for fertility rate, low skilled attendance at birth, poor maternal nutritional status and the presence of around a quarter of pregnant women have one antenatal care consultation. Only 6% of pregnant by a skilled attendant (doctor nurse, midwife or auxiliary midwife) but less than 10 % delivers in a health facility. Of women who had given birth in the preceding 2 years, 88% had received 50 Figure 10: residence, Somalia 2006 51 3.3 Access to health services and healthy environment Public health programmes are critical in the prevention and control of disease and therefore in Somalia remains underdeveloped, poorly resourced, inequitable and unbalanced. The public health care delivery system operates in a fragmented manner, maintained largely by medical of services and poor access to the rural population. Over half of the estimated health workforce operate at a level far below their intended capacity and are poorly organized, with very low utilization rates (estimated as on average, one contact every eight years, according to Rossi and Davies 2008). Not surprisingly, overall coverage of essential health services is low, especially for rural and nomadic populations. coverage (1 year olds fully immunized) doses of DPT, for measles 29%. Of mothers who gave birth in the previous percent received a Vitamin A supplement within eight weeks of the birth. Within had received a high dose Vitamin A 11 and suggest improved coverage of both immunisation and vitamin A. Overall coverage of Health Days in the two zones prior to the survey being conducted. appropriate shelter and clothing are crucial in terms of reducing exposure to disease. Throughout recently, the national micronutrient and anthropometric nutrition survey 2009 reported the use of to safe water may have taken place over the four years between surveys. Figure 11: Immunisation coverage among children under feeding). Preliminary results from the FSNAU meta-analysis 2001-2008 indicate that diarrhoea is relatively poorly funded. The relationship between malnutrition and morbidity is well established. Disease outbreaks have Very Critical despite improvements were attributed to high incidence of acute watery diarrhoea and acute respiratory tract infections (FSNAU Post Gu 2009 assessment). 3.4 Education The UNICEF conceptual model highlights inadequate education as one of the basic causes of malnutrition. According to UNICEF, only 24% of women are literate, while 20% of girls attend primary school, (44% urban, 12% rural). For every 10 boys attending primary school, there are secondary school age children attend primary school due to lack of schooling opportunities that While each of these groups of underlying causes has been discussed independently of each other, there is a clear inter-connectedness between them. Underlying causes are overlapping and have a synergistic effect so that the combined effects of a failure of all three causes are much greater than the sum of their parts. This is the foundation of the need for an integrated, regions and livelihoods. For example in urban populations, dietary diversity is much better than for the rural populations, and sub optimal care practices such as use of breast milk substitutes 4. Current Nutrition Interventions In response to persistently high rates of acute malnutrition, current nutrition interventions have been focused on saving lives through the management of acute nutrition. 4.1 Nutrition Cluster Due to weak governance structures in parts of Somalia, nutrition response programming is mainly undertaken by UN, international and national agencies. The Nutrition Working Group (NWG) was Reform, the cluster approach was introduced. From the start this was integrated into the existing NWG. Thus the Nutrition Cluster and NWG exist as a single coordination structure, referred to as the Nutrition Cluster, for nutrition activities in Somalia. The primary purpose of the Nutrition Cluster is “to support and strengthen a coordinated approach in nutrition strategic planning, situation analysis and response both in emergencies and non-emergency situations.” (Nutrition 52 53 4.2 Food Security and Nutrition Surveillance The Food Security and Nutrition Analysis Unit (FSNAU) is managed by FAO and funded by USAID/ OFDA, the EC, SIDA, UNICEF and UNHCR. It has developed a very sophisticated system of regular and exhaustive food security and nutrition assessments. Information is collected through sentinel site surveillance. Data is analysed in the context of morbidity and food security indicators. nutrition situation are published. The food security and nutrition surveillance data is an important tool providing regular situational analysis to inform and guide appropriate responses to expected caseloads of acutely malnourished and emerging needs. Additional food security information is provided through the Famine Early Warning Systems Network (FEWS NET). This is a USAID-funded activity that collaborates with international, regional and national partners to provide timely and rigorous early warning and vulnerability information on emerging and evolving food security issues. FEWSNET produces monthly food security updates, additional information to support analysis as well as program and policy development. WFP undertakes regular monitoring of market prices and has conducted baseline livelihood studies. Food security and vulnerability assessments have been conducted and published for planned for Central region in 2010. 4.3 Management of severe acute malnutrition Outpatient therapeutic feeding programmes (OTPs) for the treatment of severe acute malnutrition are being implemented across Somalia by international NGOs and UNICEF in partnership with local NGOs, according to the “Operational Guidelines for the Somalia” which were developed by account the challenging environment, reduced supervision and limited monitoring. Complicated cases are referred to stabilisation centres (SCs) for the initial period of treatment, although distance and location of centres in opposing clan territories are often barriers to access. WFP provides a caregiver and discharge rations in selected centres across Somalia. In 2009, UNICEF and training of NGO partners and distribution of feeding supplies. At the time of writing there are around 20 in patient stabilisation centres, all but four integrated into existing health structures. This scale up of services for the management of acute malnutrition is impressive but gaps remain in the geographical coverage of OTPs and SCs due to the insecure environment, fragmented current nutrition situation and interventions as of November 2010. Measuring MUAC, IDP camp, Jowhar, UNICEF Somalia, Nick Ysenburg 54 4.4 Management of moderate acute malnutrition Targeted supplementary feeding programmes (SFPs) for the treatment of moderately malnourished intervention, 20,000 are to receive ready-to-use supplementary food (supplementary plumpy) 4.5 Prevention of moderate acute malnutrition – food based interventions As a new initiative, during 2009 UNICEF launched a pilot intervention for the prevention of food (Plumpy Doz) every two months in areas showing the highest malnutrition rates, with a in the north and poor urban areas. Somalia as well as South Nugal in Puntland. This intervention was designed to prevent and treat with very limited access to nutrition services. 4.6 Institutional Feeding & School Feeding WFP is providing nutritional support to other vulnerable groups including HIV mentally handicapped, and hospitalized patients either as a take home ration or as daily meals for in patients. This intervention currently supports 60,000 people including the family protection ration. Around 90,000 school children provided oil to encourage attendance. 4.7 General food distribution WFP is providing food assistance to the rural population affected by the humanitarian crisis, the FSNAU seasonal assessments. School feeding, WFP Khalif 55 4.8 Nutrition activities delivered through the health sector Clinics and hospitals. Coverage and quality is currently limited due to overall weaknesses of the public health system. Child Health Days. These population based campaign days aim to provide at least 80 per cent deworming, provision of oral rehydration salts, water treatment tablets, hygiene education, nutritional screening, and tetanus toxoid vaccination for women. These campaign days are access to regular health services. 4.9 Other sector activities with nutrition focus acceptable practices in the region for improving infant and child feeding practices. The method over three household visits. The aim is to move from ideal recommendations to practical realistic to enhance agricultural production through cash for work programmes, distribution of packaged seed kits, tools and fertilizers. Resulting improvements to livelihood and food security should have a positive impact on nutritional status. 4.10 Strengths, weaknesses, opportunities and threats of current interventions Table 1 summarises a SWOT analysis of the current nutrition interventions in Somalia. This analysis highlights the strengths of nutrition and food security surveillance and the current interventions for the management of acute malnutrition; weakness in areas of interventions to address underlying causes of malnutrition; opportunities for integration of complementary activities and poor access, weak health systems and low human resource capacity. In such a challenging operating environment, the use of existing programmes and structures as a delivery mechanism for integrated activities is crucial. Table 2 summarises key existing initiatives and the opportunities they offer as delivery mechanisms for strengthening nutrition interventions. 56 O p p o rt u n it ie s 1. 3. 4. 6. 7. 8. 9. 11 . T h re a ts 1. 3. 4. 6. 7. 8. 9. 11 . 13 . W e a k n e ss e s 1. 3. 4. 6. 7. 8. 9. 11 . S tr e n g th s 1. 3. 4. T a b le 1 : S W O T A n a ly s is o f c u rr e n t n u tr it io n i n te rv e n ti o n s i n S o m a li a 57 P ro g ra m m e & o v e rr id in g o b je c ti v e s K e y n u tr it io n r e la te d p ro g ra m m e o b je c ti v e s K e y p ro g ra m m e a c ti v it ie s O p p o rt u n it ie s f o r in te g ra ti o n o f n u tr it io n a c ti v it ie s U n it e d N a ti o n s T ra n s it io n P la n f o r S o m a li a 2 0 0 8 0 9 i) D e e p e n in g p e a ce , im p ro vi n g s e cu ri ty a n d e st a b lis h in g g o o d g o ve rn a n ce ; (i i) I n ve st in g in p e o p le t h ro u g h im p ro ve d so ci a l s e rv ic e s; a n d (i ii) C re a tin g a n e n a b lin g e n vi ro n m e n t fo r p ri va te se ct o r le d g ro w th to e xp a n d e m p lo ym e n t a n d r e d u ce p o ve rt y se rv ic e s in cl u d in g c h ild s u rv iv a l s e rv ic e s. st a tu s H e a lth w o rk e rs , e sp e ci a lly w o m e n , in se le ct e d d is tr ic ts a re a b le t o p ro vi d e b e tt e r cu ra tiv e a n d p re ve n tiv e s e rv ic e s o n t h e b a si s o f a p a ck a g e o f e ss e n tia l s e rv ic e s. H e a lth a n d n u tr iti o n c o m m u n ic a tio n s tr a te g y a d a p te d , e xp a n d e d a n d im p le m e n te d C o m m u n iti e s a n d t a rg e te d f a m ili e s h a ve im p ro ve d ca p a ci ty in p ro ce ss in g , p re p a ra tio n a n d s to ra g e o f fo o d C o m m u n iti e s a n d t a rg e te d f a m ili e s h a ve im p ro ve d a w a re n e ss o f n u tr iti o n a l v a lu e s o f lo ca lly a va ila b le / in tr o d u ce d f o o d U N T P c a p a ci ty d e ve lo p m e n t st ra te g y H e a lth a n d n u tr iti o n c o m m u n ic a tio n s tr a te g y U N IC E F /W H O A c c e le ra te d Y o u n g C h il d S u rv iv a l In it ia ti v e ( A Y C S ) a cc e ss f o r yo u n g c h ild re n a n d m o th e rs t o a k e y se t o f c ri tic a l l ife s a vi n g in te rv e n tio n s im m e d ia te ly a n d in t h e lo n g e r te rm . (1 ) C o n tin u e w ith li fe s a vi n g e m e rg e n cy in te rv e n tio n s (2 ) E xp a n d a cc e ss t o l ife s a vi n g i n te rv e n tio n s fo r a ll ch ild re n th ro u g h in st itu tio n a liz in g h ig h im p a ct p o p u la tio n o ri e n te d s e rv ic e s in cl u d in g c a m p a ig n a n d o u tr e a ch m o d e s h e a lth c a re s ys te m t h ro u g h i n cr e a se d c o ve ra g e o f co m m u n ity b a se d s e rv ic e s a n d r e fe rr a l (4 ) U se m a ss a n d i n te r p e rs o n a l co m m u n ic a tio n s to p ro m o te p o si tiv e b e h a vi o u ra l ch a n g e a n d i m p ro ve d h e a lth s e e ki n g b e h a vi o u rs . C h ild h e a lth d a y a im t o p ro vi d e 9 0 p e r ce n t o f u n d e r a g e n a tio n w id e w ith h ig h i m p a ct ch ild su rv iv a l p o lio , d ip h th e ri a , p e rt u si s a n d te ta n u s vi ta m in A su p p le m e n ta tio n , d e w o rm in g , p ro vi si o n o f o ra l re h yd ra tio n s a lts , w a te r tr e a tm e n t ta b le ts , h yg ie n e e d u ca tio n , n u tr iti o n a l sc re e n in g , a n d t e ta n u s to xo id va cc in a tio n f o r w o m e n ; O p p o rt u n ity fo r n u tr iti o n cl u st e r to p ro vi d e in p u ts to im p ro ve q u a lit y a n d co ve ra g e o f n u tr iti o n in te rv e n tio n s p ro vi d e d th ro u g h C H D ie v ita m in A , d e w o rm in g a n d n u tr iti o n s cr e e n in g T a b le 2 : E x is ti n g p ro g ra m m e s p re s e n ti n g o p p o rt u n it ie s f o r in te g ra ti n g n u tr it io n a c ti v it ie s i n S o m a li a 58 W H O /U N IC E F G A V I H e a lt h S y s te m S tr e n g th e n in g S tr e n g th e n in g o f m a te rn a l ch ild h e a lth ce n tr e s & R e cr u itm e n t tr a in in g a n d d e p lo ym e n t o f 2 4 0 f e m a le co m m u n ity h e a lth w o rk e rs ( F C H W s) O p e ra tio n a l r e se a rc h T h ro u g h co lla b o ra tio n w ith h e a lth se ct o r, st re n g th e n e d – d e ve lo p m e n t o f st a n d a rd is e d p ro to co ls , co m p re h e n si ve t ra in in g ( p re s e rv ic e a n d in se rv ic e ) su p e rv is io n a n d m o n ito ri n g m ic ro n u tr ie n t tr e a tm e n t a n d s u p p le m e n ta tio n , p re ve n tio n a n d c o n tr o l o f d ia rr h o e a N e w i n n o va tio n o f F C H W s ca n b e t ra in e d a s b re a st f e e d in g c o u n se llo rs , to p ro vi d e n u tr iti o n co u n se lli n g fo r m o th e rs a n d y o u n g c h ild re n , t h e d is tr ib u tio n o f m ic ro n u tr ie n t su p p le m e n ta tio n , p re ve n tio n a n d c o n tr o l o f d ia rr h o e a a ct iv iti e s b re a st f e e d in g , co m p le m e n ta ry f e e d in g , g o o d h yg ie n e a n d h a n d w a sh in g p ra ct ic e s O p e ra tio n a l re se a rc h w ill h e lp i n e va lu a tio n o f fe a si b ili ty a n d e ff e ct iv e n e ss W H O C o m m u n it y b a s e d In it ia ti v e s h e a lth d e te rm in a n ts th ro u g h in te g ra te d so ci o e co n o m ic d e ve lo p m e n t w ith a ct iv e co m m u n ity i n vo lv e m e n t a n d i n te r se ct o ra l co lla b o ra tio n . d e ve lo p m e n t co m m itt e e s in 4 8 vi lla g e s in C S Z , tr a in in g o f cl u st e r re p re se n ta tiv e s, n e e d s lo ca l s o lu tio n s, im p le m e n ta tio n V ill a g e d e ve lo p m e n t c o m m itt e e s a n d re p re se n ta tiv e s in p la ce a n d tr a in e d w ith lo ca l p ri o ri tie s a n d s o lu tio n s In te r se ct o ra l c o lla b o ra tio n D e liv e ry m e ch a n is m fo r ke y n u tr iti o n m e ss a g e s sa n ita tio n p ra ct ic e s a t th e c o m m u n ity le ve l 59 E s s e n ti a l P a c k a g e o f H e a lt h S e rv ic e s (E P H S ) fo r S o m a li a 2 0 0 8 T h e E P H S is th e p ri m e m e ch a n is m fo r st ra te g ic se rv ic e p ro vi si o n o f th e p u b lic s e ct o r h e a lth s e rv ic e . It h e lp s to c la ri fy h e a lth p ri o ri tie s a n d d ir e ct s re so u rc e a ct iv iti e s a t ce n tr a l a n d r e g io n a l le ve ls , p a rt ic u la rl y in co o rd in a tio n , m a n a g e m e n t a n d su p e rv is io n o f cr e a tin g a su st a in a b le a n d a cc o u n ta b le h e a lth sy st e m . tr a in e d co m m u n ity h e a lth w o rk e r w h o co n d u ct s p ro m o tio n a l, p re ve n tiv e a n d cu ra tiv e a ct iv iti e s; ii) p ro vi d e d ; iii ) re fe rr a l h e a lth c e n tr e s a n d i v) h o sp ita ls p ro g ra m m e s C H W s ca n b e tr a in e d in p ro m o tio n o f g o o d n u tr iti o n , fe e d in g , h yg ie n e a n d sa n ita tio n p ra ct ic e s, d is tr ib u tio n o f m ic ro n u tr ie n t su p p le m e n ta tio n to w o m e n a n d ch ild re n , co n tr o l o f d ia rr h o e a l d is e a se i n cl u d in g O R S & 1 0 1 4 d a ys z in c tr e a tm e n t. N u tr iti o n s cr e e n in g a n d r e fe rr a l, a n d s u p e rv is e d t o p ro vi d e a ll th e a b o ve W H O /U N IC E F /U N F P A R e p ro d u c ti v e H e a lt h S tr a te g y ii) P ro m o tin g h e a lth y fa m ili e s h a rm fu l p ra ct ic e s a n d N e o n a ta l H e a lth s e rv ic e s Im p ro ve a ff o rd a b le r e a d y a cc e ss t o g o o d q u a lit y b ir th s p a ci n g s e rv ic e s fo r m e n a n d w o m e n . S tr e n g th e n a w a re n e ss a m o n g th e p o p u la tio n o f p ra ct ic e s. co m m u n ity m id w iv e s a va ila b le f o r p u b lic s e ct o r in a ll th re e z o n e s. P ro m o tio n o f A N C v is its , h o m e v is its a n d i n d iv id u a l co u n se lli n g b y C H W s P ro m o tio n o f e xc lu si ve b re a st fe e d in g b y C H W p ro lo n g e d b re a st fe e d in g E st a b lis h co n tin u o u s p o st b a si c a n d co m m u n ity m id w ife ry c o u rs e s in a ll th re e z o n e s. D e liv e ry m e ch a n is m fo r m a te rn a l n u tr iti o n In cl u si o n o f n u tr iti o n tr a in in g m o d u le s fo r m id w iv e s E U a n d F A O In te g ra te d S u p p o rt to R u ra l L iv e li h o o d w ith t h e a im o f m iti g a tin g t h e h o u se h o ld s in S o u th C e n tr a l S o m a lia g e n e ra tin g a ct iv iti e s, i n cr e a se d l e ve ls o f p ro d u ct io n a n d in cr e a se d a va ila b ili ty o f a g ri cu ltu ra l p ro d u ct s in th e lo ca l m a rk e ts . P lu s th e re h a b ili ta tio n o f in fr a st ru ct u re ca n a ls , m a rk e t p la ce s a n d r o a d s. E n h a n ci n g a g ri cu ltu ra l p ro d u ct io n t h ro u g h c a sh f o r w o rk p ro g ra m m e s, d is tr ib u tio n o f p a ck a g e d se e d ki ts , to o ls a n d f e rt ili ze rs Im p ro ve d l iv e lih o o d a n d f o o d s e cu ri ty s h o u ld h a ve p o si tiv e im p a ct o n n u tr iti o n a l s ta tu s F A O T ri a ls o f Im p ro v e d P ra c ti c e s p ilo t i n a cc e p ta b le p ra ct ic e s in t h e r e g io n in im p ro vi n g in fa n t a n d ch ild fe e d in g p ra ct ic e s. T h e m e th o d in vo lv e s d is cu ss io n w ith th e m o th e rs a n d ca re g iv e rs in h o u se h o ld v is its . re co m m e n d a tio n s. P ilo t in G e d o a n d H ir a n c a n b e s ca le d u p i n o th e r a re a s 60 In this section, internationally recognised, proven effective interventions are linked with the Outcome 1 Improved access to and utilisation of quality services for the management of malnutrition in women and children Child undernutrition (2008) highlights that recent studies demonstrate new commodities such as ready to use therapeutic food (RUTF) can be used effectively to manage severe acute malnutrition in community settings. The Community based management of acute the number of children who can be treated, reduces exposure to disease and reduces drop-out rates compared to standard management of acute malnutrition approach using therapeutic milks in a centre based setting (Collins et al 2006). of services for the management of severe acute malnutrition in Somalia where the weak health with respect to access to stabilisation centres or adequate facilities for referral of complicated humanitarian space is most limited. Quality of services is also an issue. Thus, the enhancement and expansion of quality interventions for the management of acute malnutrition in accordance with newly developed guidelines remains a priority. Whilst poor coverage of referral centres mobilisation as a key activity of all OTPs is an important approach to improving coverage and early diagnosis to reduce the presentation of complicated cases in need of referral. As it is such a key activity in this context, community mobilisation requires dedicated staff and resources. The results of the micronutrient and anthropometric survey 2009 underscore the importance currently limited by weakness in the health system and by poor access to and utilisation of health facilities. However, while not a remit of this strategy, health system strengthening is an overarching and commitment to timely provision of supplies, will contribute to improving treatment services. JUSTIFICATION OF OUTCOMES AND KEY APPROACHES ADOPTED IN THIS STRATEGY ANNEX 3 Child eating Plumpynut Save the Children, Somaliland 61 2, behaviour change communication strategies to improve complementary feeding practices have been proven effective in improving growth outcomes in young children. However, as the Lancet education had a greater impact when food or food supplements were provided. Furthermore, the recent review of complementary feeding (Dewey and Adu-Afarwuah 2008) found that interventions in which micronutrient supplementation alone was provided generally had little or no effect on growth. This strategy includes key outputs for addressing longer term goals of improving diet diversity and increasing consumption of local nutrient dense foods. However, in the meantime the evidence cited above underscores the importance of providing food based interventions to meet energy and protein, as well as micronutrient, requirements for the prevention of undernutrition in high risk areas of food insecurity in Somalia. In these areas where locally available foods alone will complement to continued breastfeeding and the local diet, not as a replacement. Thus food based interventions will be accompanied by counselling on continued breastfeeding, responsive feeding and good hygiene practices. The review by Dewey and Abu-Afarwuah (2008) also found that in several studies the impact of providing a complementary food in combination with nutrition education was evident only in targeting food based interventions to prevent undernutrition in the 6 to 24 months age group. In Somalia the options for products for food based interventions are corn soy nutrient supplements (LNS). LNS are a micronutrients and in which lipid is the primary source of energy. There are pros and cons to both types of products. Somalia. Its acceptability is proven, it is cheap and there are limited pipeline of blended food has more recently been questioned with varied results achieved. The energy density of blended food is low inhibits micronutrient absorption while there is a lack of animal protein. Furthermore there are two to premix blended food with oil and sugar therefore energy density is compromised. Secondly, limited supervision is possible and weak supervision has been demonstrated to reduce success blended food in the future. Child eating Plumpydoz, IDP camp Jowhar, UNICEF Somalia 62 foods that can be used at home without the need for water or premixing or cooking; they are stable and resistant to spoilage, the micronutrients do not interact; they provide additional energy and increase energy density of complementary foods; they have been proven to improve linear growth used in Somalia under operational research conditions. However with high prevalence of acute Outcome 2 Sustained availability of timely and quality nutrition information and operational research into effective responses to the causes of undernutrition response options. Whilst more is known about the underlying causes of undernutrition throughout data, less is known about the types of interventions that can impact on the problem, particularly in the Somali context. Operational research is therefore key to providing the evidence base on which appropriate programmes can be planned. Outcome 3 Increased appropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition 2009 reveal the extent of inappropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition throughout Somalia. Rates of exclusive breastfeeding are extremely low Anthropometric Nutrition survey 2009). of discarding colostrum is widespread. Infant formulas are vigorously promoted in a context of widespread poor water, sanitation and hygiene conditions. In while infants who are not breastfed in the group counselling have been demonstrated to extend the duration of exclusive breastfeeding. In Somalia individual counselling of mothers on appropriate breastfeeding practices and improving family and community understanding and support for early initiation and exclusive breastfeeding to six months are important. However, the other key priority is to address the vigorous advertising of breast milk substitutes by engaging with importers and traders. While the absence of a legislative framework is appreciated, it is important that a longer term consultative process on adoption of Poor infant and young child feeding practices, including bottle-feeding in deplorable conditions is a predisposing factor to diarrhoea and malnutrition, FSNAU, Dec, 2009 63 As highlighted in the situation analysis young child feeding practices in Somalia tend to be inadequate, with only one in ten children being appropriately fed. Energy density of complementary complementary feeding interventions concluded that carefully designed programmes that include pre-tested educational messages provided through multiple channels had an effect in improving promoted in the messages or when food supplements were provided as well. Educational strategies should focus on imparting the knowledge and develop skills to maximise use of locally-available, high-quality foods, as well as food safety, cultural beliefs and intra-family food distribution. As recommended in the review, this strategy aims to deliver nutrition counselling through multiple channels, individual, community and mass media integrated into the programmes that reach mothers Outcome 4 Improved availability and coverage of micronutrients and de-worming interventions to the population has high social and public costs leading to reduced work capacity due to high rates of illness and disability. As highlighted in the situational analysis, prevalence of both nutritional anaemia and There are different approaches to preventing micronutrient malnutrition. The best way is to ensure the consumption of a balanced diet but this requires universal access to adequate food and appropriate complex and long term issues to address. In the shorter term, micronutrient supplementation and cost-effective solutions to global challenges (Copenhagen Consensus 2008). In Somalia, bi annual vitamin A supplementation and deworming are currently key components of child health days, multiple micronutrient supplementation for pregnant and lactating women interventions and to develop new approaches to increase coverage through novel population based food consumption patterns. It is usually socially acceptable, requires no change in food habits, can local foods, such as folic acid for the prevention of birth defects. This new area for Somalia will require preliminary work before going to scale. With nearly half the population receiving humanitarian approach in low access areas. 64 Outcome 5 Nutrition is mainstreamed as a key component of health, WASH, livelihoods, food aid and education sectors require a multi sectoral response if longer term improvement in nutritional status, survival and development are to be achieved. Providing one intervention in isolation of others minimises its structures and capacity in Somalia are weak and limited and access to and utilisation of services low, the integration and enhancement of nutrition activities within multi sector programmes is Nutrition as Central to Development nutrition should be “included as a core function of services time permits”. Activities within this strategy are aimed at mainstreaming nutrition within government as well as non government structures. Increasing awareness within the line ministries of the importance of nutrition as a key determinant of health and development will be an important step to keeping nutrition on the agenda in Somalia in the longer term. Outcome 6 Improved capacity and means in country to deliver essential nutrition services The situational analysis highlights the low capacity and means in country to deliver essential country or moved to the private sector. Nutrition capacity within the regional authorities is limited. Thus the need to build local capacity to respond in the short and longer term is undeniable. Ideally this would encompass all levels, all sectors, government and non government structures. The Lancet series on undernutrition highlights that “governments must build internal capacity dedicated to addressing undernutrition to achieve longer lasting changes”. In the context of Somalia this is more challenging and thus key output of this strategy is to support the development of a local body responsible for addressing nutrition issues locally while government structures emerge and develop. Capacity development is not purely about training and organisation strengthening but also about building local ownership. The development of a nutrition capacity development strategy which is linked to the UNTP plan for capacity development is an important step to identifying priorities and advocating for cutting issues of work management, community mobilisation, team building, adopting an ethical approach, professional development. The aim is not to develop a dedicated body of highly specialised nutritionists but instead to develop relevant nutrition skills among all health workers and programmes staff from all sectors including community workers, agricultural extension workers, school teachers. Thus working with pre service training institutions for the incorporation of appropriate nutrition training modules into existing professional training curricula is a priority. The development of regional training/mentoring cells is an innovative approach to overcome challenges of limited access and supervision capacity on the ground and high staff turn over, while creating an enabling environment for partners to operate effectively is for many organisations on 65 Annex 4 Proven Effective interventions for maternal and child malnutrition (Taken from The Lancet Series on Maternal and Child Undernutrition Executive Summary January 2008) Sufficient evidence for implementation in all 36 countries Maternal and birth outcomes Iron folate supplementation Maternal supplements of multiple micronutrients Maternal iodine through iodisation of salt Maternal calcium supplementation Interventions to reduce tobacco consumption or indoor air pollution Newborn babies Promotion of breastfeeding (individual and group counselling) Infants and children Promotion of breastfeeding (individual and group counselling) Behaviour change communication for improved complementary feeding* Zinc supplementation Zinc in the management of diarrhoea Vitamin A fortification or supplementation Universal salt iodisation Handwashing or hygiene interventions Treatment of severe acute malnutrition Evidence for implementation in specific situational contexts Maternal supplements of balanced energy and protein Maternal iodine supplements Maternal deworming in pregnancy Intermittent preventive treatment for malaria Insecticide-treated bednets Neonatal vitamin A supplementation Delayed cord clamping Conditional cash transfer programmes (with nutrition education) Deworming Iron fortification and supplementation programmes Insecticide-treated bednets 66 Annex 5 Copenhagen Consensus 2008: results RANK SOLUTION 1 Micronutrient supplements for children (vitamin A and zinc) 2 3 4 5 6 Deworming and other nutrition programmes at school 7 8 9 Community based nutrition promotion 10 (Ref Horton et al 2008) 67 Annex 6 How Malnutrition affects achievement of MDGs Goal Nutritional Effect Goal 1: Eradicate extreme poverty and hunger Goal 2: Achieve universal primary education Goal 3: Promote gender equality and empower women Goal 4: Reduce child mortality Goal 5: Improve maternal health Goal 6: Combat HIV/AIDS, malaria and other diseases Source: World Bank paper: Repositioning Nutrition as Central to Development Malnutrition erodes human capital through irreversible and intergenerational effects on cognitive and physical development Malnutrition affects the chances that a child will go to school, stay in school and perform well Antifemale biases in access to food, health, and care resources may result in malnutrition, possibly reducing women’s access to assets. Addressing malnutrition empowers women more than men. Malnutrition is directly or indirectly associated with most child deaths and it is the main contributor to the burden of disease in the developing world Maternal health is compromised by malnutrition which is associated with most major risk factors for maternal mortality. Maternal stunting and iron and iodine deficiencies particularly pose serious problems Malnutrition may increase risk of HIV transmission, compromise antiretroviral therapy and hasten onset of full-blown AIDS and premature death. It increases the chances of tuberculosis infection resulting in disease and also reduces malaria survival rates 68 Key References child undernutrition and survival. The Lancet Series, Vol. th Lancet 2006; interventions in developing countries. Maternal and Child Nutrition Deyr Analysis Gu 2009 Deyr 09/10 Acta Paediatrica food compared to a corn/soy-blend-based pre-mix for the treatment of childhood moderate acute malnutrition in Niger. J Trop Paed (2010) doi:10.1093/tropej/fmq019 children in developing countries. Nutrition Reviews Report 8 and programming responses. Feinstein International Centre, Tufts University and Save the Children. Addis Ababa. Pediatrics United Nations Transition Plan for Somalia 2008-2009 WHO UNFPA UNICEF Somalia Reproductive Health National Strategy and Action Plan 2009 WFP Somalia Somaliland Food Security and Vulnerability Assessment August 2008 “Individual country nutrition strategies and programmes, while drawing on international evidence of good practice, Scaling up nutrition (SUN) - A Framework for Action, Sept. 2010