Uganda Nutrition Action Plan 2018-2025

i Uganda Nutrition Action Plan 2018–2025 Uganda Nutrition Action Plan 2018-2025 Vision “A well-nourished, healthy and productive population effectively participating in the socio-economic transformation of Uganda” Mission To end hunger, achieve food security, and improve nutrition by 2030 August 2018 ii Uganda Nutrition Action Plan 2018–2025 Contents Foreword .............................................................................................................................. iii Government commitment ................................................................................................ iv Map of Uganda ................................................................................................................... v Acronyms ........................................................................................................................... vi Glossary of Terms ................................................................................................................ 8 1 Introduction ...................................................................................................................... 9 1.1 Policy Context .............................................................................................................. 9 1.1.1 Global Framework ....................................................................................................... 9 1.1.2 Regional Frameworks ................................................................................................ 10 1.1.3 National Frameworks ................................................................................................ 11 1.2 Situation Analysis ........................................................................................................ 16 1.2.1 Nutrition Outcomes ................................................................................................... 16 1.2.2 Child Nutrition Status ................................................................................................. 16 1.2.3 Adult Nutrition Status ................................................................................................. 19 1.2.4 Causes of malnutrition .............................................................................................. 20 1.2.5 Consequences of malnutrition ............................................................................... 25 2 Review of UNAP I (2011-2016) ....................................................................................... 27 2.1 UNAP I Implementation, Gaps and Opportunities for UNAPII .................................. 27 2.2 UNAP II 2018-2025 Theory of Change ...................................................................... 31 2.2.1 Critical success factors for UNAP-II implementation linked to the ToC ...... 32 2.3 Priority Investment Areas for UNAP-II ....................................................................... 33 3 Results Chain .............................................................................................................. 35 3.1 The strategic direction ............................................................................................... 35 3.2 The Goal, Vision and Mission of UNAP II 2018-2025 ................................................ 35 3.3 Objectives and Primary outcomes .......................................................................... 36 3.3.1 Key Primary Outcomes ............................................................................................. 36 3.3.2 Intermediate Outcomes, Strategies and Priority Actions ............................... 37 4 UNAPII Implementation Arrangements .................................................................... 45 4.1 Coordination Structure .............................................................................................. 45 4.1.1 National Nutrition Forum .......................................................................................... 46 4.1.2 Policy Co-ordination ................................................................................................. 46 4.1.3 Technical Coordination ........................................................................................... 47 4.1.4 Nutrition Development Partners Committee ..................................................... 48 4.1.5 The SUN Movement Networks ................................................................................ 48 4.1.6 Sector Nutrition Co-ordination Committees ....................................................... 49 4.1.7 Decentralized Coordination ................................................................................... 49 5 Financing and Resource Mobilisation ...................................................................... 51 5.1 Financial requirements of UNAP II ............................................................................. 51 5.2 Financial resources available and the funding gap ................................................ 53 5.3 Resources Mobilization for UNAP II ............................................................................ 53 5.4 Strategic prioritization of proposed Priority interventions for the UNAP II ............... 55 6 Monitoring, Evaluation, Reporting and Learning (MEAL) ........................................ 57 6.1 Monitoring and Evaluation Framework .................................................................... 57 6.2 Risks and Mitigation Measures ................................................................................. 62 References ........................................................................................................................ 64 Annex ................................................................................................................................ 66 iii Uganda Nutrition Action Plan 2018–2025 Foreword iv Uganda Nutrition Action Plan 2018–2025 Government commitment v Uganda Nutrition Action Plan 2018–2025 Map of Uganda vi Uganda Nutrition Action Plan 2018–2025 Acronyms ACDP Agriculture Cluster Development Project AfDB Africa Development Bank ANC Antenatal Care ASSP Agriculture Sector Strategic Plan AU African Union CAADP Comprehensive Africa Agriculture Development Programme CLTS Community Led Total Sanitation CRF Common Results Framework CSA Climate Smart Agriculture DNCC District Nutrition Coordination Committees DOA Decade of Action EAC East African Community ECD Early Childhood Development ESSP Education Sector Strategic Plan FANTA Food and Nutrition Technical Assistance FAO Food and Agriculture Organisation FFD Financing for Development FSN Food Security and Nutrition GDP Gross Domestic Product GOU Government of Uganda HIRB High Iron Rich Beans HSDP Health Sector Development Plan ICN2 Second International Conference on Nutrition IEC Information, Education and Communication IMCI Integrated Management of Childhood Illnesses IPC Integrated Food Security Phase Classification ISC Implementing Steering Committee IYCF Infant and Young Child Feeding LG Local Government LLG Lower Local Government MAAIF Ministry of Agriculture, Animal Industry and Fisheries MDA Ministries, Departments and Agencies MEAL Monitoring, Evaluation, Accountability and Learning MOESTS Ministry of Education, Science, Technology and Sports MOH Ministry of Health MSN Multi sectoral Nutrition MSP Multi-sectoral Platform NAADS National Agriculture Advisory Services NBCC Nutrition Behavior Change and Communication NDP II Second National Development Plan NDPG Nutrition Development and Donor Partner Group NNF National Nutrition Forum NPA National Planning Authority NRM National Resistance Movement NUFLIP Northern Uganda Food Security and Livelihood Improvement Project OFSP Orange Fleshed Sweet Potato OPM Office of the Prime Minister OWC Operation Wealth Creation PBS Programme Based Budgeting System vii Uganda Nutrition Action Plan 2018–2025 PCC Policy Coordination Committee PDC Parish Development Committee RHITES Regional Health Integration to Enhance Services SDG Sustainable Development Goal SDP Sector Development Plan SNCC Sub-county Nutrition Coordination Committee SUN Scaling Up Nutrition UBOS Uganda Bureau of Statistics UDHS Uganda Demographic Health Survey UMFSNP Uganda Multi-sectoral Food Security and Nutrition Project UN United Nations UNAP Uganda Nutrition Action Plan UNBS Uganda National Bureau of Standards UNHCR United Nations High Commission for Refugees UNICEF United Nations Children’s Fund USAID United States Agency for International Development WB World Bank WFP World Food Programme WHA World Health Assembly 8 Uganda Nutrition Action Plan 2018–2025 Glossary of Terms Calorie Unit of heat, measurement of energy. In general, foods are made up of carbohydrates, proteins, and fats, each of which provide different number of calories Diet The use of specific intake of nutrition for health or weight-management reasons (with the two often being related). Evaluation A systematic determination of the merit, worth and significance, of nutrition programmes using criteria governed by a set of assessment standards and indicators Food Any substance consumed to provide nutritional support for the human body. It is usually of plant or animal origin, and contains essential nutrients, such as carbohydrates, fats, proteins, vitamins, or minerals. Monitoring The systematic process of collecting, analyzing and using information to track nutrition programmes’ progress toward reaching set objectives and to guide management decisions. Multi-sectoral Approach Deliberate collaboration among various nutrition stakeholder groups (e.g., government, civil society, and private sector) and sectors (e.g., health, agriculture, education, and environment) to jointly achieve nutrition policy and programme outcomes Nutrients Substances obtained from food and used in the body to provide energy and structural materials and to regulate growth, maintenance and repair of the body's tissue. Nutrition surveillance A systematic approach used to detect malnutrition and identify populations at risk of suffering from it. Obesity A chronic disease characterized by excessively high body fat in relation to lean body tissue. Overweight An excess of body weight that includes fat, bone and muscle. Stakeholder A party (organization/Institution) that has an interest in nutrition and can either affect or be affected by the nutrition work in Uganda Stunted The impaired growth and development that children (0-5years) experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation. Height-for-age is more than two standard deviations below the WHO Child Growth Standards median Vitamins Organic compounds, essential nutrients or micronutrient that an organism needs in small amounts. 9 Uganda Nutrition Action Plan 2018–2025 1 Introduction 1.1 Policy Context The Nutrition action plan addresses the nutritional needs of all population groups in Uganda and therefore was developed in the context of the available set of policy and legal frameworks. The Republic of Uganda Constitution mandates the state to promote and encourage nutrition in order to ensure a healthy Ugandan society. The various ministries, departments and agencies are required to set minimum standards, guidelines and develop policies that ensure provision of quality foods and nutrition services for Ugandans. 1.1.1 Global Framework Eliminating malnutrition in all its form is critical in breaking the intergenerational cycle of poverty that propels underdevelopment. In 2010, the Scaling Up Nutrition (SUN) a global movement to unite governments, civil society, businesses and citizens in a worldwide effort to end under- nutrition. The SUN adopted Strategy 2012- 2015 with four processes1. In May, 2012 the World Health Assembly adopted the Comprehensive Implementation Plan on Maternal Infant and Young Children Nutrition (CIP- MIYCN) and endorsed 6 Global Nutrition Targets2. In 2014, at the Second International Conference on Nutrition (ICN2), a Framework of Action with sixty policy recommendations for improving nutrition was adopted. In 2015, the 2030 1Process one: Bringing people together in the same space for action; Process two: Ensuring a coherent policy and legal framework; Process three: Aligning actions around common results and Process four: Tracking finance and mobilising resources 240% reduction in the number of children under-5 who are stunted;50% reduction of anaemia in women of reproductive age;30% reduction in low birth weight;No increase in childhood overweight; Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% and reduce and maintain childhood wasting to less than 5% by 2025. Chapter One 10 Uganda Nutrition Action Plan 2018–2025 Agenda for Sustainable Development Goals was adopted. According to the Global Nutrition Report 2015, for every 1 USD invested in nutrition a country can get 16 USD in returns, therefore improving nutrition outcomes impacts on realization of the other SDGs. In 2016, the United Nations in 2016 declared a Decade of Action on Nutrition (2016-2025) to galvanize further action towards improving nutrition. The 60 recommendations of the Framework of action were coined into six core programme areas for action3. Each programme area has recommended actions4 for which this nutrition action plan will be aligned to. In 2017, the 2030 nutrition targets were calculated based on a similar approach used for the 2025 targets, the six global nutrition targets were extended to 2030 for SDGs with adjustments in some targets while keeping others the same as for 2025; 50% reduction in the number of children under-5 who are stunted;50% reduction of anaemia in women of reproductive age;30% reduction in low birth weight;reduce and maintain childhood overweight to less than 3%;Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% and reduce and maintain childhood wasting to less than 3% by 2030. 1.1.2 Regional Frameworks At the Africa level, Heads of State and Government declared at Maputo in 2003 to commit at least 10% of their national budgets towards agriculture and food security within the Comprehensive Africa Agriculture Development Programme 3Sustainable, resilient food systems for healthy diets; Aligned health systems providing universal coverage of essential nutrition actions; Social protection and nutrition education, behavior change communication, Trade and investment for improved nutrition; Safe and supportive environments for nutrition at all ages and Strengthened governance and accountability for nutrition. 4Actions to create an enabling environment for effective action; for sustainable food systems promoting healthy diet; for trade and investment; for nutrition education and information; on social protection; for strong and resilient health systems; to promote protect and support breastfeeding; to address wasting; to address stunting; to address childhood overweight and obesity; to address anaemia in women of reproductive age; in the health services to improve nutrition; on water, sanitation and hygiene ; on food safety and antimicrobial resistance and for accountability 11 Uganda Nutrition Action Plan 2018–2025 (CAADP). Subsequently, at Malabo in 2014, the African Union (AU) made a declaration on Accelerated Agriculture Growth and Transformation and re- affirmed the CAADP commitment to end hunger and reduce stunting on the continent to 10% by 2025. 1.1.3 National Frameworks The 1995 Constitution of the Republic of Uganda, expresses Government commitment to food security and nutrition and stipulates that “Uganda shall take appropriate steps to encourage people to grow and store adequate food; establish national food reserves; and encourage and promote proper nutrition through mass education and other appropriate means in order to build a healthy state” (Objective XXII). The National Water Policy (1999), whose main objective is to manage and develop the water resources in an integrated and sustainable manner, covers all aspects of water resource management and water infrastructure development. Of the seven strategic objectives of the Water and Environment Strategic plan 2015-2020 two objectives cover provision of safe water and improved sanitation for both rural and urban areas (MOWE, 2015-2020). In 2003, The Food and Nutrition Policy was approved with a goal of ensuring food security and adequate nutrition for all the people in Uganda, for their health as well as their social and economic well-being. Since then, a number of legal, policy and planning frameworks relating to nutrition and food security have emerged at international, regional and national landscape, rendering the programming, coordination, financing, implementation and monitoring and evaluation frameworks of the Food and Nutrition Policy (2003) not sufficient in responding to the multi-sectoral approach to the fight against malnutrition in all its forms. 12 Uganda Nutrition Action Plan 2018–2025 The Education and Sports Sector’s role in nutrition programming is reinforced among others, by the Education Act (2008) and the current Education Sector Strategic Plan (ESSP 20017-2020). Under this ESSP, the Education sector has prioritized development and implementation of a strategy to address school feeding and nutrition for school-going children that include continuous sensitization of parents about their role in feeding children and providing school uniforms. Implementation of this strategy was to contribute to the provision of equitable access for all eligible children at the primary level and post-primary levels (MOES, 2017). In 2010, the Government approved the national Development plan (2010-2015) and subsequently sector development plan (2010-2025). To demonstrate commitment in the fight against malnutrition however, the government approved in 2011 the Uganda Nutrition Action Plan (UNAP) as the country`s strategic framework for scaling up nutrition. The goal of the UNAP was to reduce malnutrition levels among women of reproductive age, infants, and young children during the period 2011- 2016 and beyond the period. The second Ministry of Health Policy (NHPII) goal is "to attain a good standard of health for all people in Uganda in order to promote healthy and productive lives". The priority areas are: Strengthening health system in line with decentralization; re- conceptualizing and organizing supervision and monitoring of health systems at all levels; establishing a functional integration within the public and private sector; and addressing the human resource crisis. The NHP II (2010) aims at universal access to the Uganda National Minimum Health Care Package. The National Standards and Quality Policy (2012) was developed in order to expand regional and international trade, there is need to adopt and implement the internationally recognized and accepted Standards, Conformity Assessment and Accreditation (SMCA) practices. The policy vision is ‘to have an effective and 13 Uganda Nutrition Action Plan 2018–2025 efficient national quality infrastructure that delivers goods and services that are internationally competitive’ with a mission ‘to develop SMCA infrastructure that supports the production and consumption of quality goods and services’. In 2013, Ministry of Agriculture, Animal Industry and Fisheries (MAAIF) developed The National Agriculture Policy (NAP) of 2013. The overall objective of the agriculture policy is to achieve food and nutrition security and improve household incomes through coordinated interventions that focus on enhancing sustainable agricultural productivity and value addition; providing employment opportunities, and promoting domestic and international trade (MAAIF, 2013). Through the Agriculture Sector Strategic Plan (2015-2020) MAAIF aims at improving food and nutrition security by enhancing consumption of diverse diets at household level (MAAIF, 2015). Under the Ministry of Gender, Labour and Social Development the following policies that are sensitive to nutrition programming exist; The National Social Protection Policy, (2015); The Integrated Early Childhood Development Policy, (2016); The National Adult Literacy Policy, (2014) and The National Community Development Policy for Uganda, (2015). All these frameworks have elements of nutrition sensitive interventions for which this plan has taken advantage of. Government took steps to tackle the problem of malnutrition by setting high targets in the Uganda Vision 2040 and NDPII, the overarching planning frameworks for the country. Uganda's Vision 2040 describes long term policy objectives for the country and envisions a transformed society from a predominantly peasant and low-income country to a competitive upper middle- income country. The 2nd National Development Plan 2015/16 – 2019/20 is the overarching planning guide for Uganda and provides strategic direction to the sectors so that they can contribute to “propel the country towards middle income 14 Uganda Nutrition Action Plan 2018–2025 status by 2020”. The NDP II has human capital development as one of the four development objectives and has set child stunting as percent of under-5s as one of the Development Indicators. The target is to reduce prevalence of child stunting from 33% in 2011 to 25%and 0% by 2020 and 2040 respectively. The National Integrated Early Childhood Development (NIECD) Policy (2016) advocates for ‘supporting nutritious food production and uptake, nutrition care within the household, and community mobilization to promote the adoption of healthy behaviors and increased public awareness of the centrality of improved nutrition to community and national development to reduce prevalence of malnutrition among infants and young children, expectant and lactating mothers’. The National Integrated Early Childhood Development (NIECD) Policy (2016) stresses the importance of good nutrition alongside health care and stimulation for holistic development. The Social Protection Policy (2015) also recognizes the provision of social assistance and social security to vulnerable populations. In identifying the different necessities of Society, the social development sector ranks vulnerable groups such as children, women, orphans and older persons as being more prone to deprivation from food as well as other social services. Consequently, the Social Development Sector Strategic Investment Plan (2010/11-2015/16) focused on different social groups as a basis for interventions. The Social Sector Development Plan (2015/16-2019/20) builds on the earlier plan by prioritizing social protection (for example, the Social Assistance Grants for Empowerment (SAGE), which target the elderly) and improvement in food and nutritional security for women, children and older persons. Other initiatives in the social development sector are the Male Involvement Strategy (2015), which calls for the involvement of men to be part of healthy feeding and good sanitation. 15 Uganda Nutrition Action Plan 2018–2025 The government in 2016 developed the National Coordination Policy (NCP) for public service delivery. This NCP provides a clear framework for coordination in the management of service delivery in the public sector. This was on the basis of the sitting Governments election pledges, the National Development Plan (NDP), Medium Term Expenditure Frameworks (MTEF), Sectoral Development Plans and Annual Budget Framework Papers. The NCP 2016 provided the institutional framework for coordination of policies and government programmes. The coordination framework for this action plan has been designed taking into account the established institutional Framework for Coordination of Policy and Programme Implementation in Government (GOU, 2016). The NRM manifesto 2016-2021 proposes a cost-effective approach integrating the three pillars (Health, Education and training, while the community components (social protection, family and socialization and water and sanitation) of Human Capital Development to tracing the human capital development along the life cycle to be followed during manifesto implementation. The stages of this cycle are: pregnancy to birth, Education and Training (Early Childhood Development, Primary school age (6 – 12), Lower secondary school age (13-16), Upper secondary school age (17-18 and Tertiary and University (19-24) and Young adulthood – Community Component. Nutrition is particularly important during conception and early childhood, influencing an individual’s health, cognitive development and economic outcomes that are carried into later life. In 2017, Government of Uganda undertook a Strategic Review of SDG2 “End hunger, achieve food security and improved nutrition; and promote sustainable agriculture by 2030”. The review provide the following; the situation of hunger, food and nutrition security; the policy, legal and institutional frameworks related to food and nutrition security; the existing programmes and the extent to which they address food and nutrition security; existing financing for food and nutrition 16 Uganda Nutrition Action Plan 2018–2025 programmes. The report provided the policy actions and recommendations and this action plan has used some of the report findings as a foundation for proposing its strategic direction for 2018-2020 and beyond. In 2017, government undertook the development of the Nutrition Policy. This UNAP II will work as the implementation strategy for the National Nutrition policy. The plan has been developed taking into consideration of the achievements, challenges, opportunities, potentials and lessons leant during the implementation period of UNAP 2011-2017. The objectives, strategies and priority actions of the UNAP (2018-2025) are therefore aligned with the Nutrition Policy 2018. 1.2 Situation Analysis 1.2.1 Nutrition Outcomes The situation analysis presents nutrition outcome trends, the determinants and causes of malnutrition and their impact on existing factors of the context with the appropriate level of disaggregation (e.g. by age, sex, location, ethnicity, socio- economic status and disability) within the epidemiological, political, socioeconomic and organizational context prevailing in the country. 1.2.2 Child Nutrition Status Between 2011 and 2016, stunting decreased from 33% to 29%, while wasting decreased from 5% to 4% between 2011 and 2016, a period when the first UNAP was implemented. While progress has been made, these figures, particularly the 29% stunting level, are still poor (UDHS, 2016). 17 Uganda Nutrition Action Plan 2018–2025 Figure 1: Partial distribution of stunting (left) and wasting (right) by regions of Uganda (UDHS, 2016) The prevalence of anemia among children age 6-59 months increased slightly from 49% in 2011 to 53% in 2016 as shown in Table 1. It tends to be higher among younger age (6-23 months) than older age (24-59 months) children, with a peak prevalence of 78% among children age 9-11 months. Table 1: Comparing child nutrition outcomes in 2011 and 2016 Child Nutrition Outcomes (Objectively Verifiable Indicators) 2011 2016 Prevalence of stunting among children under five (%) 33.4 29.3 Prevalence of wasting among children under five (%) 4.7 4.0 Prevalence of low birth weight (%) 10.2 14.2 Prevalence of Under-five Overweight (%) 3.4 Prevalence of child Anemia 0-5 years (%) 49 53 The efforts by government and partners have not reduced the prevalence of anemia in the country except in two sub-regions of Kigezi and Ankole with the best statistics on water, sanitation and hygiene coverage as shown in Figure 2. Prevalence of wasting children under 5 in Uganda 18 Uganda Nutrition Action Plan 2018–2025 Child stunting and anemia occur across all wealth quintiles not only in low income households. Rates are high even in the two highest wealth quintiles with 32% of children in the lowest wealth quintile compared to 17% in the highest wealth quintile (UDHS 2016). Four in every 10 children born to mothers with no education are stunted compared with 1 in every 10 children born from educated mothers. Karamoja no longer has the highest prevalence of stunting. The most food secure regions have very high prevalence of stunting. Overall, there has been a reduction in stunting over time between 2012 and 2017 according to the Uganda trends, projection and targets for stunting prevalence presented in Figure 3. Figure 3: Uganda: Trend, projection and targets in the prevalence and number of children (under five) stunted Source: International Cooperation and Development, European Commission (http://ec.europa.eu/europeaid/uganda-nutrition-country-fiche- and-child-stunting-trends en) Further analysis indicates that children in rural areas are more likely to be anemic than those in urban areas (54% and 48% respectively). Vulnerability to anemia in children varies from region to region. For example, prevalence of anemia among children is lowest in Ankole sub region at 31%, and highest in Acholi sub region at 71% (UDHS, 2016). http://ec.europa.eu/europeaid/uganda-nutrition-country-fiche-and-child-stunting-trends en http://ec.europa.eu/europeaid/uganda-nutrition-country-fiche-and-child-stunting-trends en 19 Uganda Nutrition Action Plan 2018–2025 The rates of wasting and overweight have remained stable since 2011. However, the prevalence of acute malnutrition in Uganda is at high levels in Karamoja, West Nile and camps in Northern Uganda. 1.2.3 Adult Nutrition Status Anaemia in women of reproductive age increased from 23% in 2011 to 32% in 2016 as shown in Table 2. The proportion of women with anaemia is higher in rural areas than in urban areas (33% and 27% respectively). Table 2: Adult Nutrition Outcomes (2011-2016) Adult Nutrition Outcomes (Objectively Verifiable Indicators) 2011 Actual 2016 Prevalence of Women Anemia 15-49 years (%) 23 32 Prevalence of Adult overweight (%) women 14.6 17 Prevalence of Adult obesity (%)women 4.2 7 Prevalence of Adult overweight (%)men 4.0 7 Prevalence of obesity in adults aged 15-49 years men 0.6 1 Prevalence of Diabetes among adults 15-49 years of age Regional prevalence of anaemia among women ranges from 17% in Kigezi sub region to 47% in Acholi sub region as shown in Figure 4. In Uganda, anaemia is currently a moderate public health problem for women of reproductive age and a severe public health problem for children under five years (UDHS, 2016). The proportion of women who are overweight or obese has increased from 19% in 2011 to 24% in 2016. This has tended to increase with age, from 11% among that age 15- 19 to 34% among that age 40-49. One-third (34%) of urban women are overweight or obese, as compared to one-fifth (20%) of rural women. The proportion also increases with education and wealth; for example, 8% of women in the lowest wealth quintile are overweight or obese, compared to 42% of women in the highest wealth quintile (UDHS, 2016). 20 Uganda Nutrition Action Plan 2018–2025 Figure 4: Anemia prevalence among women in reproductive age across the country (UDHS, 2016) One in five (5) men who have more than a secondary education (19%) and who are in the highest wealth quintile (21%) is overweight or obese. It’s noted too that the proportion of women age 15-49 with any degree of anemia rose slightly from 23% in 2011 to 32% in 2016. Pregnant (38%) and breastfeeding women (34%) are more likely to be anemic than women who are neither pregnant nor breastfeeding (30%). 1.2.4 Causes of malnutrition To achieve improvement in nutrition outcomes, the various causes of malnutrition must be tackled. There are three levels of causes of malnutrition: basic causes at the societal level, underlying causes at the household and family level, and immediate causes at the individual level. This is illustrated in the conceptual framework for addressing malnutrition in all its forms in Figure 5. 21 Uganda Nutrition Action Plan 2018–2025 Figure 5: Frameworks for addressing malnutrition in all its forms Immediate causes lead directly to direct outcomes of malnutrition. The most obvious immediate cause is poor dietary intake. A person may not be getting enough required daily calories, or may be consuming food that does not have the necessary micronutrients, which can lead to chronic malnutrition (stunting) and acute malnutrition (wasting) in children or specific micronutrient deficiency such as iron deficiency which contributes to anemia in women and children. Extended and frequent illness/disease can also have an impact on the body’s ability to absorb required nutrients. An example of this is a young child who has frequent diarrhea, which can result into acute malnutrition due to poor nutrient 22 Uganda Nutrition Action Plan 2018–2025 absorption. In addition, consumption of unhealthy foods (e.g., fatty or high calorie and nutrient poor food) and physical inactivity can also lead to malnutrition in the form of overweight or obesity, which can lead to diet-related non-communicable diseases such as diabetes and heart disease. Immediate causes are exacerbated or caused by underlying causes of malnutrition. Inadequate dietary intake could be due to household food insecurity or poor child feeding practices, such as inadequate dietary diversity or early cessation of breastfeeding. Other inadequate care practices, such as failing to provide stimulation and other good early child development practices, can have negative impacts on cognitive development, which are further compounded by poor diet. Poor nutrition that may results into reduced immunity to infection, while infection results into the loss of appetite and reduces nutrient absorption, which can produce further weight loss and continued or increased levels of malnutrition. As this cycle repeats itself in a child, growth is compromised, the nutritional status worsens, and the risk of mortality continues to rise. Diseases can also be caused by poor food hygiene, (e.g., diarrhea is often caused by exposure to faeces through poor hand washing practices). This, in turn, is linked to the environment, including issues of access to water and sanitation infrastructure. Poor water and sanitation infrastructure can contaminate food, leading to an increase in disease. Lack of access to health services, such as vaccinations, also contributes to disease. Lifestyle choices, such as sedentary behaviour, can lead to overweight and obesity, particularly if there is an imbalance in the number of calories consumed versus used. Finally, basic causes influence the underlying causes, and so can lead to malnutrition. At this level, all sectors are involved. Household food insecurity can be due to a lack of income, which can be the result of low levels of education, which restrict job opportunities and other income-generating opportunities. Educational disparity can lead to increases in gender-based violence, which can 23 Uganda Nutrition Action Plan 2018–2025 have an impact on a mother’s ability to properly care for her children; this may result lead to inadequate feeding practices or the inability to take children for health services. Educational disparity and limited household resources also contribute to individuals making poor dietary choices. This may lead to consuming a diet that is low in diversity, high in fat and sugar, and low in micronutrient content (e.g., soda, chips, and biscuits). Political will can have an impact on the availability of services, including health, education, community development and agricultural extension services. It also has an impact on the enabling environment for pro-nutrition policies, which can help expand service coverage and provide funding for necessary services. As you unpack this framework, it becomes apparent that every sector has a role to play in improving nutrition. The causes of malnutrition within the household can be further explained using the factors identified as influencing infant and young child nutrition (IYCN) practices in Northern Uganda. These include women’s workload and time, teenage pregnancies and frequent pregnancies. Alcoholism and gender-based violence have also been identified among them. Negative traditional practices, polygamy, the lack of livelihoods and food insecurity are among them. These require concerted efforts from various groups within the communities to improve nutrition outcomes. According to the UDHS 2016, 66% of infants under age 6 months are exclusively breastfed. This is contrary to the recommendation that children under age 6 months be exclusively breastfed, 7% of infants consume plain water, 6% consume non-milk liquids, 8% consume other milk and 11% consume complementary foods in addition to breast milk before they reach 6 months of age. In addition, 2% of infants under age 6 months are not breastfed at all. The percentage of children exclusively breastfed decreases sharply with age from 83% of infants age 0-1 month being exclusively breastfed to 69% of infants age 2-3 months and more to 24 Uganda Nutrition Action Plan 2018–2025 43% of infants age 4-5 months. 11% of infants under age 6 months are fed using a bottle with a nipple, a practice that is discouraged because of the risk of illness to the child. Breastfeeding a child until age 2, with proper complementary feeding practices beginning after the age of 6 months, is recommended (Uganda Bureau of Statistics (UBOS): Uganda Demographic and Health Survey Report, 2016 The minimum standards with respect to infant and young child feeding (IYCF) practices among children aged 6-23 months are measured through the Minimum Acceptable Diet (MAD) indicator. The UDHS 2016 indicates that 14% of children aged 6-23 months meet the criteria for MAD. The percentage of children meeting The root causes of and factors contributing to malnutrition in Uganda are complex and multidimensional and this include: a. poverty, underdevelopment, unemployment and low socio- economic status in both rural and urban areas, often aggravated by the impact of conflict, post conflict and humanitarian emergencies and protracted crises, including natural disasters; b. inequity and inequality, poor infant and young child feeding and care practices, poor sanitation and hygiene, lack of access to education, quality health systems and safe drinking water, foodborne infections and parasitic infestations, ingestion of harmful contaminants due to unsafe food production or preparation practices; c. New and emerging challenges and trends such as climate change, pressures from population growth, urbanization, changing lifestyles and consumption patterns. 25 Uganda Nutrition Action Plan 2018–2025 MAD requirements varies by age group: 6-8 months (15%), 9-11 months (13%), 12- 17 months (15%) and 18-23 months (13%). 1.2.5 Consequences of malnutrition Malnutrition contributes to death and illness of many Ugandans each year. It also significantly reduces agricultural productivity because of productive time lost due to illnesses associated with malnutrition and time spent dealing with family illnesses or deaths associated with malnutrition. As discussed in previous earlier, it also has a disproportionate effect on children under 2, during which their cognitive development can be harmed, leading to lower levels of educational achievement. Anaemia has negative effects on productivity and the social and economic development of a nation. Women of reproductive age who are anaemic are at more risk of maternal death, having premature births, and giving birth to babies with low birth weight (< 2.5 kg). In turn babies who are premature or born with low birth weight are at high risk of death before their first birthday. Children who suffer from underweight and/or wasting are at increased risk of mortality from illnesses such as diarrhoea and pneumonia. The effects of undernutrition on the immune system are wide ranging and tend to be more frequent and severe in wasted children. Stunting in childhood has short-term and long-term consequences that affect health and human capital development. In addition to poor physical growth, stunting increases childhood risk of infection and mortality, and affects development, learning capacity and school performance. Later it affects productivity, wages and reproductive health. It can also lead to excessive weight gain later in life, which contributes to higher levels of overweight and obesity. These conditions lead to increased risk of nutrition-related chronic diseases such as diabetes and heart disease. Overweight and obese children are likely to stay obese into adulthood and are 26 Uganda Nutrition Action Plan 2018–2025 more likely to develop non-communicable diseases like diabetes and cardiovascular diseases at a younger age. Prevention of childhood obesity therefore, needs to be given high priority to support improvement in adult nutrition outcomes as well. 27 Uganda Nutrition Action Plan 2018–2025 2 Review of UNAP I (2011-2016) 2.1 UNAP I Implementation, Gaps and Opportunities for UNAPII In March, 2011 Uganda joined the global Scaling Up Movement in nutrition (SUN). During the same year, 2011, Cabinet under Minute 293 (CT 2011) approved the Uganda Nutrition Action Plan (UNAP) as the Government Strategic Plan for Scaling up Nutrition in Uganda until 2016. The UNAP1 specifically aimed at scaling- up multi-sectoral efforts to establish a strong nutrition foundation for Uganda’s development. The goal of the UNAP 1 was to reduce malnutrition levels among women of reproductive age, infants and young children from 2011 through 2016 and beyond with five objectives5: During the implementation of UNAP, various frameworks emerged at the global, regional and national landscape for nutrition programming. The key framework that commit to improving nutrition by 2025 is the Framework for Action on Nutrition, adopted at the Second International Conference on Nutrition (ICN2), commit to improving nutrition by 2025. The framework has 60 recommendations. Furthermore, a number of nutrition actors increased, an opportunity that required coherent and harmonized efforts to coordinate the use of resources, getting more partners aligned with national priorities and translating these efforts towards common nutrition goals and objectives into comprehensive nutrition plans. 5Improve access and utilization of Maternal, Infant and Young Child Nutrition health related services; Enhance consumption of diverse diets; Protect households from the impact of shocks & other vulnerabilities that affect nutritional status; Strengthen the policy, institutional framework & capacity to effectively plan, implement & monitor nutrition; and Create awareness, maintain interest & commitment to improve support for nutrition Chapter Two 28 Uganda Nutrition Action Plan 2018–2025 While at the inception of the first UNAP in 2011, no standard guidance for generation of a good nutrition action plan was available to define what constitutes quality nutrition plans, in 2016, the SUN movement developed a checklist on the criteria and characteristics of “a good” national nutrition plans. The checklist recognizes the universality of malnutrition and the need for actions that address malnutrition in all its forms. It also recognizes the attainment of good nutritional status especially among children and women of reproductive age, as both a marker and a maker of sustainable development, with 12 out of 17 Sustainable Development Goals (SDGs) relevant to nutrition (IFPRI, 2015). Overall, Uganda under UNAP-1 made substantial progress in most of the nutrition indicators used in tracking achievements especially stunting, wasting and exclusive breast feeding. However, the country performed poorly on other nutrition indicators such as anemia among children and women of reproductive age and low birth weight. Nevertheless the country is on a positive trend of reducing prevalence of stunting and has indeed achieved the UNAP-1 target of reducing stunting levels down to 29%. Despite the achievements, holistic implementation of nutrition intervention remains weak concentrating in most food insecure and vulnerable areas of the country. Nutrition stakeholder interventions are not well coordinated and often do not align with what is articulated in the national frameworks for nutrition and other related policies. Systems for material, financial and human resources tracking for UNAP-1 implementation were not sufficeinttherefore, financing for nutrition was not well appreciated and thus was never well established. In general, the budget transparency for nutrition interventions across sectors during the UNAP mplementation was low due to high levels of aggregation of budgets making information on nutrition sensitive and specific expenditure scarce and difficult to track. 29 Uganda Nutrition Action Plan 2018–2025 The UNAP 2 therefore is informed by the review findings of UNAP-1, SDGs, Agenda 2030 and the outcome documents of the Second International Conference on Nutrition (ICN2) held in 2014 that constitute the Framework for Action on Nutrition. The plan is further informed by the six pillars6of the Decade of Action on Nutrition (2016-2025), the Principles of Engagement7 of the Scaling Up Nutrition (SUN) Movement and the need for a multi-sectoral, multi-stakeholder approach – from national to community levels and the SUN checklist, that sets out the essential ‘ingredients’ for sound national plans8; The second Uganda Nutrition Action Plan 2018-2025 is built on the Lancet 2013 and prepared in line with the Lancet guide as shown in Figure 6. The content scope is cognizant of the global, regional and national commitments. It is multi- sectoral in nature and so linked to the coordination and implementation of nutrition related intervention to end hunger to achieve food security and improve nutrition by 2025 and beyond. 6Aligned health systems providing universal coverage of essential nutrition actions, sustainable, resilient food systems for healthy diets, Social protection and nutrition education, behavior change communication; Safe and supportive environments for nutrition at all ages; Strengthened governance and accountability for nutrition 7Transparency about intentions and impact, inclusiveness, Rights based, willingness to negotiate, predictability and mutual accountability, cost-effectiveness, continuous communication, integrity and ethical, mutual respect and do non-harm 8Situation analysis and policy and programming review; Stakeholders’ engagement and political commitment process; Costs and budgetary framework; implementation and management arrangements and Monitoring, evaluation, operational research and review arrangements. 30 Uganda Nutrition Action Plan 2018–2025 Figure 6: Framework for actions to achieve optimum foetal and child nutrition development (Lancet, 2013) There are three categories of program areas and interventions required to address the immediate, basic, and underlying causes of malnutrition. The program areas fall under three main headings: Nutrition-specific interventions programmes that address the immediate determinants of foetal and child nutrition and development – adequate food and nutrient intake (Lancet, 2013). It also considers the feeding, caregiving and parenting practices including low burden of infectious diseases. Nutrition-sensitive interventions and programmes address the underlying determinants of foetal and child nutrition and development – food security; adequate care giving resources at the maternal, household and community levels. Access to health services safe and hygienic environment equally considered. It incorporates specific nutrition goals and actions. Nutrition governance that addresses the basic causes of malnutrition is provided for in the guideline. 31 Uganda Nutrition Action Plan 2018–2025 2.2 UNAP II 2018-2025 Theory of Change The Theory of Change (ToC) that underpins UNAP-II is grounded on the six steps9 of the SUN movement strategy monitoring, evaluation, accountability and learning (MEAL) results framework and the SUN road map 2016-2020 (SUN March 2018) and the nutrition decade of action. Figure 7 presents the proposed UNAP-II theory of change. The UNAP II Theory of Change. Figure 7: UNAP-II Theory of Change 9STEP 1: Multiple stakeholders from different sectors come together to tackle malnutrition and build an enabling environment for improving nutrition with equity; STEP 2: Multiple stakeholders from different sectors change their behaviors and commit to achieving common nutrition results for everyone, everywhere; STEP 3: Multiple- stakeholders mobilize resources and align implementation to optimize coverage and effectiveness of their actions; STEP 4: Results are achieved through aligned implementation in a far greater way than what could have been achieved by each stakeholder on its own; STEP 5: Women, children, adolescents and families thrive leading to the end of malnutrition by 2030 (SDG 2.2); STEP 6: Better nutrition contributes to the achievement of SDGs UNAP results and targets achieved through aligned implementation UNAP II - GOAL End all forms of malnutriti on by 2030 Resource mobilization and alignment of implementation to optimize coverage and effectiveness Well-nourished women, children, adolescents and families thrive leading to the end of malnutrition Multiple stakeholder platforms to tackle malnutrition with equity Change of behaviors of stakeholders and commitment to achieving common nutrition results at lower local governments, district and National Levels Im p lem en tatio n o f Sp ecific, Sen sitive an d G o vern an ce N u tritio n In terven tio n s National Enabling Environment (Legal and Policy frameworks: Constitution of Uganda 1995, Uganda vision 2040, NDP II, Ruling Government Manifesto, and institutional structures) Intermediate Nutrition Outcomes Targets International Enabling Environment (SDGs agenda 2030, WHA Targets 2025, Global NCD targets, SUN frameworks) 32 Uganda Nutrition Action Plan 2018–2025 2.2.1 Critical success factors for UNAP-II implementation linked to the ToC  Designing and implementation of the standard mechanisms for reporting, monitoring and surveillance of the food security situation on a regular basis to ensure proactive responses nationally and in respective regions.  Ensuring that the programme Based Budgeting System (PBS) reports generated by Local Governments clearly state the targets achieved under nutrition service delivery programmes; through integrating nutrition indicators in the PBS.  Developing a functional resource mobilization strategy for nutrition to address nutrition financing gaps and enforce mutual accountability mechanisms in monitoring multi-sectoral nutrition programme financing and link investments to nutrition outcomes  Enforcing regulations on quality assurance of agricultural inputs including fertilizers, seeds, seedlings and stocking materials and agricultural chemical  Establishment and operationalization of a comprehensive National food reserve system; through promoting mass production and fortification of major staples such as maize, beans, millet and rice as food security crops by facilitating their production at regional level.  Enforcing consumption of nutrient rich foods through mandatory industrial food fortification and bio-fortification for major staples.  Developing an integrated management programmes for antenatal micronutrient supplementation, intermittent preventive treatment for malaria in pregnancy, iron and folic acid supplementation for non-pregnant women,  Designing and undertaking popular behavioral change campaigns to promote all-inclusive good nutrition and hygiene practices for infants, 33 Uganda Nutrition Action Plan 2018–2025 children, pregnant mothers, people living with disabilities and the elderly. This should be complemented by targeted interventions like iron, zinc and vitamin A supplementation.  Conducting operations research aimed at enhancing staple food fortification, and popularizing locally available complementary foods to boost the treatment of severe/acute and other forms of malnutrition.  Undertaking nutrition policy reviews, institutional reforms, streamlining coordination structures down-to the parish level, delivery linkages with stakeholders highlighting implementation mandates and milestones. 2.3 Priority Investment Areas for UNAP-II The investment areas for UNAP II are aligned with the Uganda Vision 2040, NDP II, and the ruling government manifesto. Globally, UNAP-II is fully aligned to the six cross cutting areas of the United Nations Decade of Action on Nutrition (2016- 2025) that are integrative areas for impact, derived from the ICN2 FfA recommendations and relevant to related SDGs. Figure 8 shows the investment areas while Table 3 illustrates the alignment. Figure 8: Six Pillars of investment areas for Nutrition Action 34 Uganda Nutrition Action Plan 2018–2025 The investment areas are aligned with the Uganda vision 2040, the National Development Plan II as well as the manifesto of the governing party and the SDG Agenda 2030. Table 3: Alignment of UNAP II strategies to the priority Action area for investment Priority Action Area for investment in the decade of action UNAP-II Strategies Vision 2040 & NDP II SDG Agenda 2030 Aligned health systems providing universal coverage of essential nutrition actions  Promote Optimal maternal, infant, young child and adolescent nutrition practices √ √  Promote micronutrient intake in children and women of reproductive age √ √  Increase coverage of management for acute malnutrition in stable and in emergency situations √ √  Integrate Nutrition services in prevention, control and management of infectious diseases. √ √  Integrate Nutrition services in prevention, control and management of non-communicable diseases. √ √ Sustainable, resilient food systems for healthy diets  Promote production and consumption of bio- fortified and industrial fortified foods √ √  Promote and increase production, access and consumption of diverse high nutrient value and safe foods √ √ Social protection and nutrition education, behavior change communication  Promote access to integrated early childhood development and child protection services for improved nutrition √ √ Trade and investment for improved nutrition  Promote trade and investment for improved nutrition through involving the business community in scaling up nutrition actions √ √ Safe and supportive environments for nutrition at all ages  Promote access to classroom education through school food and nutrition programmes as guided by the 2013 school feeding and nutrition guidelines √ √  Promote integration of food and nutrition programming into water, sanitation and hygiene (WASH) services √ √ Strengthened governance and accountability for nutrition  Strengthen nutrition governance at central and local government levels √ √  Institutionalize nutrition research and knowledge management for decision making √ √ 35 Uganda Nutrition Action Plan 2018–2025 3 Results Chain 3.1 The strategic direction The UNAP-II is guided by the Uganda Vision 2040 (Uganda Vision, 2014) and the NDP II (2015) priorities and seeks to address 12 out of the 17 SDGs but with specific consideration of SDG-2. It sets out priorities, strategic results and targets in three thematic programme areas of nutrition specific, nutrition sensitive and nutrition governance. This UNAP-II is the strategic implementation plan for the Nutrition Policy 2018. Nutrition is one of the contributing factors to the attainment of NDP-II aspirations of graduating to middle -Income status. The strategic direction of the plan is presented in this chapter. 3.2 The Goal, Vision and Mission of UNAP II 2018-2025 Goal To end food insecurity and all forms of malnutrition in children under 5 years of age, adolescent girls, pregnant and lactating women including older persons by 2030 Vision A well-nourished, healthy and productive population effectively participating in the socio-economic transformation of Uganda Mission To end hunger, achieve food security, and improve nutrition by 2030. Chapter Three 36 Uganda Nutrition Action Plan 2018–2025 3.3 Objectives and Primary outcomes Over the planned period 2018-2025, the UNAP II seeks to: (1) Increase access to and utilization of nutrition-specific services by children under 5 years of age, adolescent girls, pregnant and lactating women and other vulnerable groups (2) Increase availability and utilization of nutrition sensitive service by children under 5 years of age, adolescent girls, pregnant and lactating women and other vulnerable groups (3) Strengthen the enabling environment for scaling up nutrition specific and nutrition sensitive interventions. 3.3.1 Key Primary Outcomes Achievement of the Uganda Nutrition Action Plan (2018-2025) targets will be measured through a set of primary, intermediate, process and policy/capacity indicators. The key primary outcomes and targets based on UNAP-1, Second National Development Plan, National Standards Indicator Framework, and World Health Assembly 2025 targets as per the Comprehensive Implementation Plan on maternal, infant and young child framework (WHO, 2012) and the Comprehensive Global Monitoring Framework (GMF) for the prevention and control of non-communicable diseases nutrition targets. Details of the individual indicators have been provided in the Monitoring and Evaluation Framework (Annex). Below are the ten (10) primary targets from the above frameworks; I. A 40% reduction in the number of children under-5 who are stunted by 2025 and 50reduction in the number of children under-5 who are stunted by 2030; 37 Uganda Nutrition Action Plan 2018–2025 II. A 50% reduction of anemia in women of reproductive age by 2025 and 2030; III. A 30% reduction in low birth weight; IV. Reduce and maintain childhood overweight to less than 3% V. Achieve an Increase the rate of exclusive breastfeeding in the first 6 months up to at least 70% VI. Reduce and maintain childhood wasting to less than 3%; VII. A 30% relative reduction in mean population intake of salt/sodium VIII. A 25% relative reduction in the prevalence of raised blood pressure IX. A 10% reduction in prevalence of insufficient physical activity X. No increase in the prevalence of obesity and diabetes 3.3.2 Intermediate Outcomes, Strategies and Priority Actions Objective 1: Increase access to and utilization of nutrition-specific services by children under 5 years of age, adolescent girls, pregnant and lactating women and older persons; Intermediate outcomes  Improved maternal, infant, young child and adolescent nutrition practices  Increased micronutrient intake in children and women of reproductive age  Increased coverage of management for acute malnutrition in stable and in emergence situations  Increased coverage of nutrition services in disease prevention, control and management of infectious diseases  Increased coverage of nutrition services in disease prevention, control and management of diet related non-communicable disease Strategy 1.1: Promote optimal maternal, infant, young child and adolescent nutrition practices Priority actions I. Promote and support health and nutrition education to increase the level of awareness of good nutrition. II. Promote integration of nutrition services in all routine and outreach 38 Uganda Nutrition Action Plan 2018–2025 health services and programmes targeting children and mothers. III. Manage nutrition for sick children, pregnant and lactating mothers, and other women of reproductive age. IV. Integrate the management of severe and moderate acute malnutrition into routine health services. V. Promote utilization of antenatal and postnatal care services among all pregnant and lactating mothers to monitor child growth, and the health and nutrition status of both the mother and the child. VI. Promote and support breastfeeding policies, programmes, and initiatives. VII. Promote and support appropriate complementary feeding practices. VIII. Promote proper food handling, hygiene, and sanitation through increased knowledge, use of safe water, and hand washing practices at household level. IX. Promote infant and young child nutrition practices X. Promote community based and health facility-based growth promotion and monitoring. Strategy 1.2: Promote micronutrient intake in children and women of reproductive age Priority actions I. Provision of Vitamin A supplementation for children II. Promote deworming in Children III. Avail Iron folic acid supplementation for pregnant women IV. Promote storage and consumption of iodized salt V. Encourage the utilization of therapeutic zinc supplementation with ORS VI. Promote the consumption iron fortified staple foods I. Promote consumption of home-based fortified foods Strategy1.3: Increase coverage of management for acute malnutrition in stable and in emergency situations Priority actions i. Implement integrated management of acute malnutrition targeting refugee children and women. ii. Implement integrated management of acute malnutrition targeting children and women from refugee host communities and other areas in the country. 39 Uganda Nutrition Action Plan 2018–2025 iii. Implement integrated management of acute malnutrition targeting food insecure communities such as Karamoja. Strategy 1.4: Integrate Nutrition services in prevention, control and management of infectious diseases. Priority actions i. Integrate diet therapy into routine disease management ii. Promote actions that prevent and improve management of childhood diarrhoea and gastro intestinal infestations iii. Ensure universal access to and use of insecticide-treated nets iv. Prevent and treat malaria for pregnant women, children and other vulnerable groups v. Promote and sustain universal and age-appropriate immunization services vi. Prevent and treat diarrhea children vii. Prevent and treat Acute Respiratory infections (ARIs) for children viii. Prevent and treat childhood fevers Strategy 1.5: Integrate Nutrition services in prevention, control and management of non-communicable diseases. Priority actions I. Promote actions that prevent and improve management nutrition-related non-communicable diseases II. Train Health Care Providers on Diet and Nutrition Related Non-Communicable Diseases at all levels III. Sensitizing communities on The Tips for a Healthy Life Style; Eating Healthy and exercising regularly Objective 2: Increase availability and utilization of nutrition sensitive service by children under 5 years of age, adolescent girls, pregnant and lactating women, older persons and other vulnerable groups Intermediate Outcomes  Increased production, access and consumption of diverse diets  Increased production and consumption of fortified foods  Improved access to Social protection programmes with a food and nutrition security objective 40 Uganda Nutrition Action Plan 2018–2025  Improved coverage water, sanitation and hygiene (WASH)  Increased access to classroom education  Increased access to integrated early childhood development and child protection services  Increased participation of the business sector in scaling up nutrition. Strategy 2. 1: Promote and increase production, access and consumption of diverse high nutrient value and safe foods. Priority actions I. Promote indigenous food production and processing of diversified nutritious foods at household and community levels. II. Promote the production, accessibility and consumption of a variety of cereals, legumes, fruits, animal–source foods, including fish, meat eggs and dairy products III. Promote the diversification of crops including underutilized traditional crops, appropriate production of animal-source products as needed. IV. Strengthen local food production and processing, especially by smallholder V. Promote food safety interventions at different levels VI. Promote post-harvest handling and value addition technologies along the food value chain VII. Promote the uptake and use of the adapted small-scale irrigation technologies/options VIII. Scale up nutrition sensitive and climate smart agriculture projects that build resilience to climate change and other shocks to the food supply system. IX. Strengthen monitoring and surveillance for compliance to food control systems. X. Improve storage, preservation, transport and distribution technologies and infrastructure to reduce seasonal food insecurity, food and nutrient loss and waste. Strategy 2. 2: Promote production and consumption of bio-fortified and industrial fortified foods Priority actions 41 Uganda Nutrition Action Plan 2018–2025 I. Promote industrial food fortification and consumption of fortified maize flour, wheat in households and institutions II. Promote bio fortification of orange flesh sweet potatoes, and iron rich beans, especially in all high production zones III. Generate foundation seed for bio-fortified crops and promote production of bio-fortified foods Strategy 2.3: Promote integration of food and nutrition security services in social protection programmes. Priority actions I. Mainstream nutrition interventions into social protection programmes and into humanitarian assistance safety net programmes II. Promote social transfers to support livelihoods for the most vulnerable households and communities. III. Develop and implement programmes for special social assistance and for livelihood promotion and protection in areas with high levels of malnutrition. IV. Implement the school feeding and nutrition programme in humanitarian situations and refugee V. Promote energy saving technologies targeting women VI. Mainstream nutrition in the youth livelihood programme implementation VII. Strengthen and scale up early warning systems on food and nutrition information from community to national levels. Strategy 2.4: Promote integration of food and nutrition programming into water, sanitation and hygiene (WASH) services. Priority actions I. Promote access and utilization of safe water at household level II. Scale up Community Led Total Sanitation (CLTS) practices III. Promote food safety and hygiene education at household level and in schools IV. Promote safe water supply in rural and urban areas Strategy2.5: Promote access to classroom education through school food and nutrition programmes as guided by the 2013 school feeding and nutrition guidelines. 42 Uganda Nutrition Action Plan 2018–2025 Priority actions i. Mobilize school going children to access nutrition education during Integrated Child Health Days. ii. Implement the parent led School feeding and Nutrition using sustainable school feeding models iii. Link OWC to school garden projects iv. Expand and improve provision of safe water Supply and sanitation infrastructure to Schools within the mandate of the education sector v. Mainstream nutrition education in key development programmes. vi. Strengthen nutrition education in pre-primary, primary school, health and agriculture training institutions. Strategy 2.6: Promote access to integrated early childhood development and child protection services for improved nutrition. Priority actions i. Promote early childhood care education ii. Promote food security and nutrition for ECD iii. Promote child protection services iv. Promote primary Health care, WASH and environment hygiene for ECD Strategy 2.7: Promote trade and investment for improved nutrition through involving the business community in scaling up nutrition actions. Priority actions I. Conduct a mapping exercise for the business community actors in food and nutrition. II. Develop and implement strategy for business community actors’ participation in scaling up nutrition as per the SUN guidelines. III. Strengthen the capacity of the business in agricultural inputs production, processing and marketing. IV. Support and facilitate Village Saving and Loan Associations and SACCOs for improved access to incomes, food and nutrition security. Objective 3: Strengthen the enabling environment for scaling up nutrition specific and nutrition sensitive interventions. 43 Uganda Nutrition Action Plan 2018–2025 Intermediate Outcomes  Functional Nutrition governance structures  Improved political commitment for nutrition  Improved behaviors to advocate, partner and commitment towards common results improved functional and institutional capacity  Coherent policy implementation of multi-sectoral nutrition programmes  Improved knowledge and evidence for nutrition programming Strategy 3.1: Strengthen nutrition governance at central and local government levels. Priority actions i. Enhance capacities of nutrition coordination structures at local government to coordinate, plan, implement and monitor the implementation of UNAP-II. ii. Enhance capacities of nutrition coordination structures in MDAs to coordinate, plan, implement and monitor the implementation of the nutrition Policy and UNAP-II. iii. Support the implementation of the nutrition advocacy and communication strategy for UNAP-2at national and local government level. iv. Implement the National Family Policy to promote the rights of the family members and foster nutrition and wealth creation. v. Mainstream nutrition in the Uganda Women empowerment programme implementation. vi. Implement Nutrition Behavior Change Communication and Advocacy Strategy (BCC strategy) 2015. Strategy 3. 2: Institutionalize nutrition research and knowledge management for decision making. Priority actions I. Create capacity within national institutions to operate and maintain a National Information Platform for Food and Nutrition; II. Strengthen capacity to track progress in meeting UNAP-II objectives to 44 Uganda Nutrition Action Plan 2018–2025 prevent malnutrition and monitor nutrition investments; III. Build the capacity of national policy makers and nutrition programme planners and implementers to make better use of evidence in designing and implementing nutrition-related policies, programmes and projects. IV. Establish the academic and research institutions network for scaling nutrition research in the country. V. Establish and implement systems for mobilizing and tracking finances for nutrition in the public, private and civil society sectors VI. Design and implement a Monitoring, Evaluation, Reporting and Learning plan for UNAP-II. 45 Uganda Nutrition Action Plan 2018–2025 4 UNAPII Implementation Arrangements 4.1 Coordination Structure The coordination structure for the UNAP is derived from the institutional Framework for Coordination of Policy and Program implementation in Government (IFCPPI) under Minute No 257 (CT 2003 (NCP, 2016). Effective coordination is a critical component of nutrition improvement as it creates the necessary enabling environment for scale-up, empowerment and sustainability of interventions. Although in nutrition we understand what works and in many ways how it should work, the challenge is to ensure interventions are delivered across sectors through an efficient, cost-effective and coherent adherence to the principles of good governance. Parliament Chapter Four Policy Coordination Committee (PCC) Implementation Coordination Steering Committee (ICSC) Multisectoral Nutrition Technical Coordination Committee (OPM) Sector Nutrition Coordination Committees 127 District Nutrition Coordination Committees CSOs Network Developmen t Partners Business Network Municipal Council Nutrition Coordination Committee Sub county/Town Council Nutrition Coordination Committee Division Council Nutrition Coordination Academic & Research Network Cabinet Figure 9: The UNAP coordination and implementation structure with stakeholder inter and intra coordination and multiplicity. 46 Uganda Nutrition Action Plan 2018–2025 In order to effectively implement this action plan, partners are encouraged to adhere to the SUN Movement Principles of Engagement and act according to their commitments, including mobilizing resources and aligning implementation to optimize coverage and effectiveness of their actions. As a result, we will notice improvements in feeding and dietary practices, increased access to required services among families especially those most at risk of malnutrition. The nutrition status of Ugandans will improve and the country will be able to show how nutrition has contributed to the achievement of the 2030 Agenda for Sustainable Development and the accompanying Global Goals (SDGs). 4.1.1 National Nutrition Forum National Nutrition Forum (NNF) will be the Apex tier of engagement on nutrition by all stakeholders. The NNF will bring together Government Ministries, Departments and Agencies, representatives from Local Governments, Development Partners, Private Sector, Civil Society Organisations, Academia and Research Institutions. Hosted and Chaired by the Prime Minister, the Nutrition Forum will meet annually to review the implementation of the nutrition policy and provide policy advice and advocacy for nutrition programming. Prior to the Forum event, a technical review meeting of Permanent Secretaries; Heads of Corporation and Agency and representatives from Local Governments, Civil Society Organizations, Private Sector, Academic and Research Institutions will be held annually to provide input to the deliberations for the NNF. 4.1.2 Policy Co-ordination Policy co-ordination will be done through three entities: A Policy Coordination Committee, the Implementation Steering Committee (ISC) and the Parliamentary Sub-Committee on Nutrition. The Policy Coordination Committee will meet annually to review progress on key nutrition indicators in the country and to provide policy direction. The Policy Coordination Committee (PCC) will 47 Uganda Nutrition Action Plan 2018–2025 be chaired by the Prime Minister. The Implementation Steering Committee (ISC), which will include key line Permanent Secretaries, will meet annually to review progress on performance of key nutrition indicators, analyze budget performance of nutrition programmes, analyze the constraints to implementation and provide strategic direction. Recommendations from the Policy Coordination Committee (PCC) and the Implementation Steering Committee (ISC) will be fed into the Parliamentary Sub- Committee on Nutrition, which will approve the key policy and financial decisions and then forwarded to the Nutrition Multi-Sectoral Technical Committee for implementation. 4.1.3 Technical Coordination Technical co-ordination of nutrition will be done through the Nutrition Multi- Sectoral Technical Committee, which will comprise key technical experts from government, development partners, the private sector, academia, and civil society. The committee will be chaired by the Permanent Secretary, Office of the Prime Minister. Th e Nutrition Multi-Sectoral Technical Committee will be supported by the department of Strategic Coordination and Implementation (SCI) which will be responsible for supporting the coordination of joint planning and review with departments as well as development partners, civil society, the private sector and academia; they will Monitor and evaluate the national nutrition response in the country; Mobilizing resources and support for nutrition response; Providing national standards and norms for nutrition; advocate for the development of nutrition structures and adequate resource allocation; Lobbying for the establishment of a consolidated nutrition fund by development partners and facilitating cross-sector collaboration, higher-level committees notwithstanding. Cabinet 48 Uganda Nutrition Action Plan 2018–2025 4.1.4 Nutrition Development Partners Committee The Nutrition Development Partners Committee will be responsible for promoting and identifying funding resources for the nutrition agenda in Uganda. It will also promote joint resource mobilization, allocation and support; responding to the proposed development partners’ consolidated nutrition fund. Beyond that the committee will provide policy guidance on the alignment of nutrition programs to the Sustainable Development Goals and the nutrition commitments of the United Nations Development Agency Fund and other international organizations. This committee will be composed of representatives of nutrition development partners and will feed into the policy and technical co-ordination committees. 4.1.5 The SUN Movement Networks The SUN Movement provides the platform to enable stakeholders work together to define shared objectives, mobilize resources and deliver solutions. While the Development Partners SUN Network and the Government has been active during UNAP 1 implementation, the Civil Society Network, Business Network, academic and Research Network will be established/strengthened during the first year of the second UNAP implementation. Each Network will have its terms of reference developed in line with the Global SUN Movement taking into consideration the Uganda Legal and policy context. The SUN Monitoring, Evaluation, Accountability and Learning (MEAL) system will be used to measure the extent to which the SUN Networks adhere to the SUN Movement Principles of Engagement, commitments and alignment of implementation to optimize coverage and effectiveness of actions proposed in the UNAP. Annually a Joint-Assessment will be held to measure progress towards (I) Bringing people together in the same space for action (ii) Ensuring a coherent policy and legal framework (iii) Aligning actions around the Integrated Common Results Framework (ICRF) for this UNAP and (iv) Tracking finance and mobilizing resources towards achieving results and impacts. 49 Uganda Nutrition Action Plan 2018–2025 4.1.6 Sector Nutrition Co-ordination Committees During the first UNAP, Ministries, Departments and Agencies formed nu t r i t i on Coord in at i on Committees to oversee the c o -ordination of nutrition programmes and support implementation by central government departments, local governments, the private sector, academia and civil society. Dur ing UNAP I I , the capacities of sector nutrition coordination committees will be strengthened to be able to plan, budget, implement and monitor nutrition specific, nutrition sensitive and governance interventions. Sector coordination Committees wil l prepare and share annual work plan with the UNAP Secretariat, Office of the Prime Minister. This annual work plan will work as a tool to facilitate the coordination of implementation of the UNAP within and across sectors. Nutrition focal persons in each sector will facilitate the co-ordination of nutrition programming within the sector. Under the UNAP II, effort will be taken for Kampala Capital City Authority to come on board in the coordination of implementation of the UNAP through established legal and policy framework. 4.1.7 Decentralized Coordination In order to scale up the nutrition governance for creating an enabling environment to implement the nutrition interventions at household level, UNAP II, will cascade the decentralized coordination of nutrition programming. This will be through the district nutrition coordination committees that were established in UNAP I to the community level through established lower local government structures i.e. municipality, town council, division and sub-county levels. Actual implementation of development programmes happen at household and community level and this require capacities of various actors at the community level to be strengthened. Through the parish chiefs, capacities of the existing parish development committees (PDCs) will be strengthened to coordinate the implementation of multi-sectoral nutrition interventions under the UNAP at 50 Uganda Nutrition Action Plan 2018–2025 household and community levels. Local Council executive committee members will be mobilized to support the implementation of the plan at village and house levels across the over 60,000 villages in the country. Terms of reference and standard operation procedures to guide the various actors from the district to the parish levels will be developed for technical guidance. 51 Uganda Nutrition Action Plan 2018–2025 5 Financing and Resource Mobilisation Uganda’s central and local governments, with support from other agencies and development partners, will finance UNAP-II through resource mobilization and alignment of implementation to optimize coverage and effectiveness of multi- sectoral nutrition interventions. Development partners will complement the government strategies, plans and budgets to implement the UNAP. Existing and available resources for nutrition within the national budget, private sector and development partners must be coordinated effectively to maximize impact. Financing the UNAP has to take into consideration the changing global context that has resulted into a more complex aid architecture: the emergence of new actors in the nutrition programming beyond one sector, development of new financing instruments e.g. programme base budgeting system and new forms of dialogues that require improved coordination, harmonization and alignment with national priorities. 5.1 Financial requirements of UNAP II Using the 3-Step approach to track budget resources on nutrition, the costing available resources has been identified and the funding gap generated for use to finalise the cost that is required to fund the other interventions in the UNAP 2018- 2025. The 2013 Lancet Series was used to categorize existing interventions as nutrition-specific and nutrition-sensitive. The identified funding gap will be used to develop a resource mobilization plan. The review of government national budgets of 2018-2023 helped to understand the level of detail easily accessible in government investment on nutrition level of aggregation of budget to support the nutrition specific and sensitive interventions Chapter Five 52 Uganda Nutrition Action Plan 2018–2025 will be determined. On alignment of activities from the existing frameworks some vital activities will be left unfunded and these unfunded activities will be used to generate the resource mobilization plan that will be shared with development partners, civil society and private sector for support. The formulation of the UNAP costing framework has been based on the existing sector plans and budgets. The process involved identification of existing budgets for nutrition sensitive and specific interventions in sector budget framework papers and plans. For effective costing of the UNAP II and the Nutrition Policy, an analysis of budgets as per sector Budget Framework Papers of 2018-2023 and previous expenditures to interventions was undertaken ans it provides a basis for generating the financing and implementation of the 2nd UNAP. The scope of this financing plan is therefore limited to interventions already available in the medium term budget frameworks with some areas already budgeted whille others fall under unfunded priorities. Ongoing and already identified funded programmes whose funding source is already known have been included in the costing plan. The following programmes whose funding sourceare already available have been included to form part of the financing plan for the UNAP II.  The Uganda Multi-Sectoral Food Security and Nutrition (2015-2019) Project funded by Global Agriculture and Food Security Program (GAFSP) at a cost of grant of US$27.64 million and implemented in 15 Districts. This project will come to an end in 2019, two years from the start of UNAP 2 implementaion.  The Uganda Nutrition Information Platform for Nutrition (2018-2021) project to be implememted during the first four years of the UNAP 2018-2025. The NIPN an EU/DFID funded project will enhance evidence-based programming that will contribute to improve nutrition outcomes. 53 Uganda Nutrition Action Plan 2018–2025  The Development initiative for Northern Uganda (DINU) 2018-2023 to be implemnted Karamoja, Lango, West Nile, Acholi, Teso sub-regions: during the first five years of the UNAP 2018-2025. 5.2 Financial resources available and the funding gap The UNAP II estimated resources will be available from Government, Development Partners, Civil Society Organizations and the private sector. This will be guided by sharing of the Key priorities and stakeholders availing their estimated financial commitments for UNAP II (2018-2025). The various intermediate results and priority actions together with the potential responsible stakeholders are presented in the implementation matrix shown in the Annexure. 5.3 Resources Mobilization for UNAP II The resources mobilization plan shows that a larger share of the resources is planned to be mobilized from the Government of Uganda and the remaining from Development Partners and the Private Sector (Table 4). A key strategy for resource mobilization for the funding gap is ensuring that the Multi-Sectoral Nutrition Technical Committee develops a resource mobilisation strategy for the UNAP II. Table 4: Finance and Investment Plan for UNAP II Priority Action Area for investment in the decade of action UNAP II Objectives UNAP-II Strategies Lead sector Indicative financial resource investment GOU DP Aligned health systems providing universal coverage of essential nutrition actions Obj 1  Promote Optimal maternal, infant, young child and adolescent nutrition practices  Promote micronutrient intake in children and women of reproductive age  Increase coverage of management for acute malnutrition in stable and in emergency situations MoH 10Direct Nutrition investment - $184m 11Indirect investments in nutrition - $5755.33m 10 Extracted from the Ministry of Health SDP (MoH SDP, 2016-2020 page 81) 11 Extracted from the Ministry of Health SDP – it is an amalgamation of program areas costs of RMA Health, Child Health, Immunization, Malaria, TB and Non-communicable diseases (MoH SDP, 2016-2020 page 81) 54 Uganda Nutrition Action Plan 2018–2025 Priority Action Area for investment in the decade of action UNAP II Objectives UNAP-II Strategies Lead sector Indicative financial resource investment GOU DP  Integrate Nutrition services in prevention, control and management of infectious diseases.  Integrate Nutrition services in prevention, control and management of non- communicable diseases. Sustainable, resilient food systems for healthy diets Obj 2  Promote production and consumption of bio-fortified and industrial fortified foods  Promote and increase production, access and consumption of diverse high nutrient value and safe foods MAAIF 126500.8 Billion Social protection and nutrition education, behavior change communication;  Promote access to integrated early childhood development and child protection services for improved nutrition MGLS D 131,25Tn Trade and investment for improved nutrition;  Promote trade and investment for improved nutrition through involving the business community in scaling up nutrition actions MoTIC 14Indirect nutrition investment UGX 830,000 Bln Safe and supportive environments for nutrition at all ages  Promote access to classroom education through school food and nutrition programmes as guided by the 2013 school feeding and nutrition guidelines. MoES 1512,470.21 Bln  Promote integration of food and nutrition programming into water, sanitation and hygiene (WASH) services MoWE 168698.6 Billion Strengthened governance and accountability for nutrition Obj 3  Strengthen nutrition governance at central and local government levels OPM DINO – Euro 6m  Institutionalize nutrition research and knowledge management for decision making OPM NIPN – Euro 2.4m 12Investment costs that will contribute to attainment of Nutrition outcomes extracted from MAAIF SDP, 2015/16-2019/20 (Page 75-76) 13 Extracted from the National Integrated Early Childhood Development Policy Action Plan (2016-2021) Uganda (Page 23) 14 Investment costs that will contribute to attainment of Nutrition outcomes extracted from MoTIC SDP, 2015-2020 (Page 109) 15 Extracted from the MOES ESSP (2017/18-2019/20) Uganda (Page29) – Costs for SO1 and SO3 7Extracted from the MOWE Project Sector Investment (2015/16-2019/20) Uganda (Page 56) – Sub sectors: Water and Sanitation Devt. Infrastructure and Water for Production Infrastructure 55 Uganda Nutrition Action Plan 2018–2025 5.4 Strategic prioritization of proposed Priority interventions for the UNAP II There will be need to prioritize interventions and activities in case of funding constraints. This is due to the high prevalence of child stunting and anaemia in the country. A large proportion of children 6-23 months are having low minimum acceptable diet, while a large number of school children are going hungry at school. There is a high refugee influx, a large number of children with severe acute malnutrition in West Nile and Karamoja. These nutrition indicators will be prioritized for scale up during UNAP II. Activities to be prioritized are those that contributes to: (1) increased coverage of maternal infant, young child and adolescent nutrition activities; (2) scale-up of integrated management of acute malnutrition among children under five; and (3) those that prevent anaemia among women of reproductive age (15-49 years). If scaled up to 90% coverage, nutrition-specific interventions have potential to reduce the prevalence of stunting by estimated 20% (The Lancet Maternal and Child Nutrition Series June 2013). When accompanied with nutrition-sensitive interventions that address the underlying and basic causes of under nutrition and implemented by multiple sectors, the impact of nutrition specific interventions will be significantly great and considerably more sustainable. The Nutrition sensitive interventions to be scaled up will be those already in existence and have an entry point for embedding in nutrition message/objective. The nutrition sensitive interventions if implemented to scale in a consistent and concerted manner with the right targeting of households with children under the age of 5 years, adolescents, women of reproductive age and other vulnerable groups will solve 70% of the nutrition problems. In order to implement the nutrition specific and nutrition sensitive interventions for better nutrition outcomes, the 56 Uganda Nutrition Action Plan 2018–2025 enabling environment will be strengthened at all levels of implementation. These interventions will be predominantly delivered at household level. Prioritized nutrition sensitive interventions will be those that are most cost-effective with proven evidence on reducing stunting and are easy to implement at large scale through the existing delivery platforms in the sectors of Agriculture, social development, education, trade, industry and cooperatives, water and environment. Other activities to prioritize will be those focusing at the removal of bottlenecks and providing enabling environment. 57 Uganda Nutrition Action Plan 2018–2025 6 Monitoring, Evaluation, Reporting and Learning (MEAL) 6.1 Monitoring and Evaluation Framework The M&E framework for UNAP is aligned with the National standards indicator framework (NSI) or the second national development plan (NDP II), and the government annual performance review systems. For effective and coherent coordination of implementation of the second UNAP a comprehensive Monitoring and Evaluation (M&E) Plan will be developed. The M&E plan will describe the M&E framework, indicators, processes, sources of data, methods and tools that the ministries, Departments and Agencies will use to collect, compile report and use data to provide feed-back as part of the national M&E machinery. Office of the Prime Minister will take lead in the monitoring and evaluation of the progress and results of implementing the UNAP. The M&E framework has been developed to capture the progress at four levels; the primary outcome indicators will measure the progress towards the global nutrition targets. The Intermediate outcome indictors will monitor how specific diseases and conditions on the causal pathways affect national trends relating to the global nutrition targets; process indicators will monitor programme and situation-specific progress; policy environment and capacity indicators will measure the political economy and capability within the country. The intermediate, process and policy environment indicators will facilitate regular monitoring of the progress towards the achievement of primary target outcomes at national level. Annual reports on the UNAP implementation will be generated through holding joint annual review meetings. The reports will describe the overall progress on the implementation of intermediate, process and policy outcomes related to the realization of the primary nutrition outcomes. In addition, the reports will generate Chapter Six 58 Uganda Nutrition Action Plan 2018–2025 a mapping of the commitments made by Ministries, Departments and Agencies, Development Partners, Civil Society Organizations, business community, academia and research actors to assess progress and achievements. The reports will contribute to the UNAP MEAL Plan reporting needs. Tracking implementation of policy and UNAP progress and country-specific commitments will be based on the Scaling up Nutrition Movement Joint Assessments, panel surveys, administrative assessments in the sectors and ad hoc validation studies performed by the multi-sectoral nutrition platforms. The annual reports will provide opportunities for discussion among multi-sectoral stakeholders of the progress under the UNAP 2018-2025. An open and inclusive dialogue among all stakeholders to evaluate the progress of the UNAP (2018-2025) will be convened at mid-term (2021) after the UDHS 2021 and at the end of the UNAP (2025). Progress in achieving the global nutrition and diet-related NCD targets is to be measured throughout the UNAP period at decentralized and national levels. Targeted programme and policy evaluations will be carried out, with support by the multi-sectoral nutrition stakeholders to identify good practices. Details of the Monitoring and Evaluation framework are in Table 5. 59 Uganda Nutrition Action Plan 2018–2025 Table 5: Monitoring and Evaluation Framework # Indicator Baseline Target Data Source(s) Frequency of reporting 2016 2020 2025 World Health Assembly and NCD Target Indicators 1 Proportion of stunted children under five years of age 29 24.4 19.8 UDHS 5 years 2 Prevalence of infants born below 2500 g (low birth weight) 10 8.5 7 UDHS 5 years 3 Prevalence of overweight children under five years of age 3.7 2.7 2 UDHS 5 years 4 Prevalence of wasting in children under five years of age 2 1 0 UDHS 5 years 5 Proportion of overweight women of reproductive age 17 17 17 UDHS 5 years 6 Proportion of obese women of reproductive age 7 7 7 UDHS 5 years 7 Prevalence of raised blood glucose/diabetes among persons aged 18+ years 3.4 3.4 3.4 UDHS 5 years 8 Prevalence of raised blood pressure among persons aged 18+ years. 24 21 18 UDHS 5 years 9 Prevalence of anaemia in pregnant women 32 22 11.5 UDHS 5 years 10 Prevalence of anaemia in children under five years 53 39 24.5 UDHS 5 years 11 Mean population intake of salt per day in grams in persons aged 18+ years. - - - UDHS 5 years 12 Exclusive breastfeeding for the first six months 66 68 70 UDHS 5 years 13 Prevalence of persons aged 18+ years consuming less than 400 grams of fruit and vegetables per day 14 17 20 UDHS 5 years Intermediate Outcome Indicators 1 Proportion of underweight women of reproductive age 9 4.5 0 UDHS 5 years 2 Prevalence of overweight in adolescents 19 11.5 4 UDHS 5 years 3 Prevalence of obesity in adolescents 17 10 3 UDHS 5 years 4 Prevalence of diarrhea in children under 5 years of age 20 10 0 UDHS 5 years 60 Uganda Nutrition Action Plan 2018–2025 5 Prevalence of malaria in children under 5 years of age 30 15 0 UDHS 5 years 6 Prevalence of ARI in children 0- 5years 9 4.5 0 HMIS 1 year 7 Percentage of children 0-5years with fever 33 15.2 0 HMIS 1 year 8 prevalence of HIV infection 6.2 4 0 UDHS 5 years 9 Percent of women 15-49years of age taking 3+ doses of Fansider 17 33.5 50 HMIS 10 Tuberculosis incidence per 1,000 populations - - - HMIS 5 years 11 Gross enrollment ratio of in secondary school 24.5 35.5 45.5 EMIS 5 years 12 Gender parity index for secondary school level 0.9 1 1 EMIS 1 year Process Indicators 1 Initiation of breastfeeding within one hour of birth 66 83 100 UDHS 5 years 2 Proportion of children aged 6 to 23 months who consume minimum Acceptable Diet (MAD) 14 17 20 UDHS 5 years 3 Proportion of children aged 6 to 23 months who receive a Minimum Diet Diversity (MDD) 40 62.5 85 UDHS 5 years 4 Proportion of women of reproductive age consuming a Minimum Diet Diversity (MDD) 40 62.5 85 UDHS 5 years 5 Percentage of the population consuming food that is fortified according to standards - - - UDHS 5 years 6 Proportion of health facilities that are Baby Friendly Hospital Initiative (BFHI) certified - - - UDHS 5 years 7 Percentage of births in baby friendly facilities - - - UDHS 5 years 8 Proportion of mothers of children 0–23 months who have received counseling, support or messages on optimal breastfeeding at least once in a year - - - UDHS 5 years 9 Proportion of children 6–59 months with severe acute malnutrition admitted for treatment - - - UDHS 5 years 10 Proportion of children 6–59 months receiving Vitamin A supplementation 55 72.5 90 UDHS 5 years 61 Uganda Nutrition Action Plan 2018–2025 17 SP- Sector Performance Reports 11 Proportion of pregnant women receiving Iron and Folic Acid supplementation 88 94 100 UDHS 5 years 12 Number of trained nutrition professionals /100,000 population UDHS 5 years 13 Percentage of households that have iodized salt (>0 ppm) 99 100 100 UDHS 5 years 14 Proportion of children under 5 years old with diarrhea receiving oral rehydration salts (ORS) and Zinc 47 73.5 100 UDHS 5 years 15 Proportion of children aged 12–59 months receiving at least one dose of de-worming medication 60 75 90 UDHS 5 years 16 Use of insecticide treated nets in children aged 0–5 years 62 81 100 UDHS 5 years 17 Use of insecticide treated nets in women of reproductive age - - - HMIS 1 year 18 Percentage of children age 12-23 months who have received all basic vaccines 55 60 70 UDHS 5 years 19 Contribution of staple foods to caloric intake 50 72.5 95 UDHS 5 years 20 Proportion of children 6-23months of age who consume iron rich foods of iron fortified foods 40 55 70 UDHS 5 years 21 Proportion of children 6-23months of age who consume vitamin A rich foods of Vitamin A fortified foods 67 73.5 80 UDHS 5 years 22 Proportion of the population covered by social protection services - - - SP17 reports 1 year 23 Percentage of safe rural water supply coverage 66 79 81 SP reports 1 year 24 Percentage of safe urban water supply coverage 80 100 100 SP reports 1 year 25 Percentage of safe rural sanitation coverage 82 95 100 SP reports 1 year 26 Percentage of safe urban sanitation coverage 95 100 100 SP reports 1 year 27 Proportion of women aged 20–24 in early motherhood 24.8 17.4 10 UDHS 5 years 28 Persistence of undernourishment 16 10 0 UDHS 5 years 62 Uganda Nutrition Action Plan 2018–2025 6.2 Risks and Mitigation Measures It is important that this UNAP is able to identify and manage risks that may affect its smooth implementation. The Risk and mitigation for the UNAP II has been summarized as shown in the table below, looking at the risk level and proposed mitigation measures. Table 6: Risk Mitigation Plan for the UNAP II Risk Risk level Risk Mitigation Emphasis on delivering general sector mandates may compromise programming for delivery of nutrition sensitive outcomes High Align and use nutrition-sensitive indicators at all levels to ensure that programme activity implementation is nutrition-sensitive Low institutional capacity to lead and manage the UNAP High Enhance the capacities of sectors to effectively lead, coordinate and manage implementation of the UNAP Inadequate and low skilled human capacity especially at community level to deliver multi-sectoral nutrition services High Human resource development in multi-sectoral nutrition services delivery and allocate adequate number of skilled staff to implement the UNAP at all levels especially at sub county Policy and Capacity Indicators 1 Existence of Multi-Stakeholder Platforms (MSP) 3 4 5 SUN MEAL reports 1 year 2 Existence of functional information systems for nutrition - - - SUN MEAL reports 1 year 3 Annual National budget spendinganalysis completeness - - - SUN MEAL reports 1 year 4 Annual Development Partner budget spendinganalysis completeness - - - SUN MEAL reports 1 year 5 Resource mobilization gap analysis completeness - - - SUN MEAL reports 1 year 6 Coherent implementation of the International Code of Marketing of Breast-milk Substitutes - - - SUN MEAL reports 1 year 7 Coherent implementation of the maternity act - - - SUN MEAL reports 1 year 8 Coherent implementation of the nutrition policy - - SUN MEAL reports 1 year 63 Uganda Nutrition Action Plan 2018–2025 Risk Risk level Risk Mitigation and parish level through the existing structures under the Local Governments Inadequate funding of UNAP Medium Prioritize interventions and activities and develop a funding mobilization strategy. Low commitment and collaboration by some key stakeholders Medium Provide and strengthen Multi-Sectoral Nutrition Platforms to ensure sector and development partner policy, strategies and plans on nutrition are in alignmentwith the UNAP Political Will and Government Commitment fades Low Continue keeping nutrition high on the country’s development agenda through holding regular Nutrition Forum at National, Regional and district level. Monitor and track inclusion of nutrition objectives in the political agenda (manifesto) of the Government Occurrence of natural and man- made Disasters (e.g. Floods, drought, deforestation Medium Need to monitor all possible disasters closely and respond appropriately. Prioritize areas historically known to suffer from emergencies prepare emergency/disaster response plans Climate change and environment deteriorates Medium Foster the adoption of sustainable farming practices (climate smart agriculture, water- scarce, etc.) that also contribute to the resilience of agro-ecosystems, and efficient water and energy management techniques. Continued Influx of refugees High Monitor closely and adjust plan as appropriate. Embed the nutrition governance objective in refugee and disaster response plans 64 Uganda Nutrition Action Plan 2018–2025 References Government Of Uganda: (2007) Uganda Vision 2040. “A Transformed Ugandan Society from a Peasant to a Modern and Prosperous Country within 30 years” National Planning Authority (2015): National Nutrition Planning Guidelines for Uganda. (Government of Uganda) Uganda Bureau of Statistcs (UBOS)and ICF; 2017 Uganda Demographic and Health Survey 2016: Key Indicators Report. Kampala, Uganda: UBOS, and Rockville, Maryland, USA: UBOS and ICF. Uganda Bureau of Statistcs (UBOS) 2007.Uganda Demographic and Health Survey 2006: Ministry of Finance Government of Uganda Meera Shekar, et-al (Oct 2016) - An Investment Framework for Nutrition inUganda: Educing Stunting and Other Forms of Child Malnutrition – World Bank NW Washington DC MAAIF (2010) Agriculture for Food and Income Security; Agriculture Sector Development Pomeroy-Stevens A, et-al; Prioritizing and Funding the Uganda Nutrition Action Plan. Food and Nutrition Bulletin 2016, Vol. 37(4S) S124-S141 SPRING USAID MAAIF 2010; Agriculture Strategy and Investment Plan: 2010/11- 2014/15. Ministry of Agriculture, Animal Industry & Fisheries, Kampala Ministry of Health (2015) Health Sector Development Plan: 2015/16 – 2019/20 (Kampala, Government of Uganda) Ministry of Health (2016) Annual Health Sector Performance Report: Financial Year 2015/16 (Kampala, Government of Uganda) FAO (2017) FAOSTAT; Available at: http://faostat3.fao.org/faostat-gateway/go/to/home/E WFP and NPA (2015); The Cost Hunger in Uganda: Implications on National Development and Prosperity, in Uganda Ministry of Water and Environment (2015) Water and Environment Sector Development Plan: 2015/16 – 2019/20 (Kampala, Government of Uganda) UNHCR (2016) Uganda Refugees and Asylum Seekers in Country as 1 November 2016 UNICEF: (2013) Lancet Nutrition Series, Ministry of Gender Labour Social Development (2016) Social Development Sector Plan: 2015/16 – 2019/20 (Kampala, Government of Uganda) WFP / ECA: (2013) The Cost of Hunger in Uganda Summary Report, Ministry of Education and Sports (2017) Education and Sports Sector strategic Plan: 2017/18 – 2019/20 (Kampala, Government of Uganda) FANTA:Uganda PROFILES (2013); Reducing Malnutrition in Uganda: Estimates to Support Nutrition Advocacy, Global Nutrition Report (2015): Actions and Accountability to Advance Nutrition and Sustainable Development. World Health Assembly Res. 65.6: (2012). Comprehensive implementation plan on maternal, infant and young child nutrition SUN Movement: (2016) – Sun Strategy and Roadmap: 2016 - 2020 Ssewanyana, S. N. & Kasirye, I. (2010) Food security in Uganda: a dilemma to achieving the millennium development goal. 41 Arimond, M. et al. (2011) Dietary Diversity as a Measure of the Micronutrient Adequacy of Women’s Diets in Resource-Poor Areas: Summary of Results from Five Sites. FANTA-2 Bridg. FHI 360 16–25. Ministry of Gender Labour Social Development (2016) National Integrated Early Childhood Development Policy Action Plan: 2016 – 2021 (Kampala, Government of Uganda) Ruel, M. T. Operationalizing Dietary Diversity: (2003)A Review of Measurement Issues and Research Priorities. J. Nutr. 133, 3911S–3926S. 65 Uganda Nutrition Action Plan 2018–2025 SUN Movement: (2016) – SUN self Assessment Report 2016; Joint Assessment by Multi-Stakeholder Platforms Smith, L. C. & Subandoro, A. (2007)Measuring food security using household expenditure surveys.. doi:10.2499/0896297675 World Health Assembly Res. 66.8: (2013) WHO Global Monitoring Framework for the Prevention and Control of Non-Communicable Diseases UNICEF: (2017) – Development Initiative for Northern Uganda: Ministry of Trade, Industry and Cooperatives -2015. Sector Development Plan: 2015/16 – 2019/20 (Kampala, Government of Uganda) Ministry of Health (2010) Integrated Managment of Acute Malnutrition Guidlines: (Kampala, Government of Uganda) Food and Agriculture Organisation : (2014) The second International Conference on Nutrition; Comitting to a Future free of Malnutrition, (United Nations) Unaited Nations: (2017) The Decade of Action : 2016 – 2025 SUN UN Network: Checklist on the Criteria and Characteristics of good national Nutrition Plans World Bank: (2016): An Investiment Framework for Nutrition in Uganda: Reducing Stunting and Other forms of Malnutrition World Food Programme: (2017) A Strategic Review of Sustainable Development Goal 2 in Uganda. (Government of Uganda) SUN Movement (2015): Guidlines for Using the Common Results Framework Planning tool World Health Organization: (2014). Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition. WHO. Organ. 24 SUN Movement: (2018) – SUN Monitoring, Evaluation, Accountability and Learning (MEAL) Updated version Office of the Prime Minister: (2017)Multi sectoral Nutrition Coordination Comittee Orientation Guidlines for Facilitators (Government of Uganda) NIPIN Project: (2017) ; Nutrition Information Platforms for Uganda (Government of Uganda and EU) 66 Uganda Nutrition Action Plan 2018–2025 Annex Implementation Matrix Intermediate Result Priority Action Lead sector Other stakeholders Strategic Objective 1. To increase access to and utilization of nutrition specific services among households of children under 5 years of age, Adolescents, women of reproductive age and other vulnerable groups18 1.1 Improved maternal, infant, young child and adolescent nutrition practices Promote infant and young child nutrition practices MoH DPs Promote community and health facility- based growth promotion and monitoring MoH MoLG, MGLSD, DPs Promote and support health and nutrition education to increase the level of awareness of good nutrition. MoH MoLG, MGLSD, DPs Promote integration of nutrition services in all routine and outreach health services and programmes targeting children and mothers. MoH DPs Manage nutrition for sick children, pregnant and lactating mothers, and other women of reproductive age. MoH DPs, MGLSD Integrate the management of severe and moderate acute malnutrition into routine health services. MoH DPs Promote utilization of antenatal and postnatal care services among all pregnant and lactating mothers to monitor child growth, the health and nutrition status of both the mother and the child. MoH DPs, MGLSD Promote and support breastfeeding policies, programmes and initiatives. MoH Parliament, DPs 18 Priority actions drawn from, 2nd National Development plan (2015-2020); Sector Development plans (2015-2020); The Rome Declaration Framework of Actions (2014); Consultations with district and national stakeholders, The Ruling Government Manifesto 2016-2021 and Nutrition Development Partners Projects and Programmes 67 Uganda Nutrition Action Plan 2018–2025 Intermediate Result Priority Action Lead sector Other stakeholders Promote and support appropriate complementary feeding practices. MoH MGLSD, DPs Promote proper food handling, hygiene and sanitation through increased knowledge, use of safe water and hand washing practices at household level. MoH MoWE, MoES, MGLSD, DPs 1.2 Increased micronutrient intake in children and women Vitamin A supplementation for children MoH MoES, DPs Promote deworming in Children MoH MoES, DPs Promote Iron folic acid supplementation for pregnant women MoH MGLSD, DPs Promote consumption of iodized salt MoH MoTIC, DPs Promote therapeutic zinc supplementation with ORS MoH DPs Promote consumption of iron fortified staple foods MAAIF MoH, MGLSD, DPs Promote consumption of home-based fortified foods MAAIF MoH, MGLSD, DPs 1.3 Increased coverage of management for acute malnutrition in stable and inemergence situations. Implement Integrated management of acute malnutrition targeting refugee children and women. MoH OPM, MoLG, DPs Implement Integrated management of acute malnutrition targeting children and women from refugee host communities and other areas in the country. MoH OPM, DPs Implement Integrated management of acute malnutrition targeting food insecure communities such as Karamoja MAAIF OPM, MoLG, DPs 1.4 Improved coverage ofnutrition services in disease Integrate diet therapy into routine disease management MoH DPs 68 Uganda Nutrition Action Plan 2018–2025 Intermediate Result Priority Action Lead sector Other stakeholders prevention, control and management of infectious Promote actions that prevent and improve management of childhood diarrhea and gastro intestinal infestations for improved nutrition. MoH DPs Ensure universal access to and use of insecticide-treated mosquito nets MoH MGLSD, DPs Prevent and treat malaria for pregnant women and children and other age groups MoH DPs Promote and sustain universal coverage of available routine immunization services MoH MoLG, DPs Prevent and treat acute respiratory infections (ARIs) for children MoH DPs Prevent and treat childhood fevers MoH DPs 1.5 improved coverage ofNutrition services in disease prevention, control and management of diet related non-communicable disease and communicable diseases Promote actions that prevent and improve management of nutrition-related non- communicable diseases MoH DPs Train Healthcare providers on diet and nutrition related Non-communicable diseases at all levels MoH DPs Sensitize communities on The Tips for a Healthy Life Style; Eating Healthy and exercising regularly MoH MGLSD, DPs Strategic Objective 2: Increase availability and utilization of nutrition sensitive service by children under 5 years of age, adolescent girls, pregnant and lactating women, older persons and other vulnerable groups 2.1 Increased production, Increased access and Promote food safety interventions at different levels MAAIF MoTIC, MoH, DP’s 69 Uganda Nutrition Action Plan 2018–2025 Intermediate Result Priority Action Lead sector Other stakeholders consumption of diverse high nutrient value and safe foods Scale up nutrition sensitive and climate smart agriculture projects that build resilience to climate change and other shocks to the food supply system. MAAIF DPs Strengthen local food production and processing, especially by smallholder MAAIF DP Promote indigenous food production and processing of diversified nutritious foods at household and community levels. MAAIF MoTIC, DP Promote the uptake and use of the adapted small-scale irrigation technologies/options MAAIF MoWE, DP Promote the diversification of crops including underutilized traditional crops, appropriate production of animal-source products as needed. MAAIF MoWE, DPs Promote production, accessibility and consumption of a variety of cereals, legumes, fruits, animal –source foods, including fish, meat eggs and dairy products MAAIF DPs Promote post-harvest handling and value addition technologies along the food value chain. MAAIF MoTIC, DPs Strengthen monitoring and surveillance for compliance to food control systems. MAAIF DPs Development of processing/packaging tools and equipment MoTIC MAAIF, DPs Improve storage, preservation, transport and distribution technologies and infrastructure to reduce seasonal food insecurity, food and nutrient loss and waste MAAIF MoW, DPs 70 Uganda Nutrition Action Plan 2018–2025 Intermediate Result Priority Action Lead sector Other stakeholders 2.2 Increased production and consumption of fortified foods Promote production of bio-fortified foods. MAAIF DPs Generate foundation seed for bio-fortified crops. MAAIF DPs Increase awareness on the consumption of fortified foods. MoH MGLSD, DP’s Promote micronutrient enhancement through industrial and bio-fortification MoH MoTIC, DP’s 2.3 Improved coverage of nutrition Security services in Social protection programmes Mainstream nutrition interventions into social protection programmes and into humanitarian assistance safety net programmes MGLSD OPM, DPs Develop and implement programmes for special social assistance and for livelihood promotion and protection in areas with high levels of malnutrition. MGLSD OPM, DPs Implement the school feeding and nutrition programme in humanitarian situations and refugee MoES OPM, DPs Promote social transfers to support livelihoods for the most vulnerable households and communities. MGLSD OPM, MoLG, DPs Promote energy saving technologies targeting women MGLSD MoTIC, DPs Mainstream nutrition in the youth livelihood programme implementation MGLSD MoLG, DPs Strengthen and scale up early warning systems on food and nutrition information from community to national levels. MAAIF OPM, DPs 71 Uganda Nutrition Action Plan 2018–2025 Intermediate Result Priority Action Lead sector Other stakeholders 2.4 Increased access to classroom education Mobilize school going children to access nutrition education during Integrated Child Health Days. MoES DPs Mainstream nutrition education in key development programmes. MoES OPM, MGLSD, DPs Strengthen nutrition education in pre-primary, primary school, health and agriculture training institutions. MoES MoH, DPs Implement the parent led School feeding and Nutrition using sustainable school feeding models MoES OPM, DPs Link OWC to school garden projects MoES MAAIF, DPs Expand and improve provision of safe water supply and sanitation infrastructure to Schools within the mandate of the education sector MoWE MoES, DPs 2.5 improved coverage water, sanitation and hygiene (WASH) in Food and nutrition programmes Promote access and utilization of safe water at household level. MOWE MoLG, DPs Scale up Community Led Total Sanitation (CLTS) practices MoH MoWE, DPs Increase access to improved Water and sanitation, food safety and hygiene MoH MoWE, DPs Increase access to safe water supply in rural and urban areas MoWE, DPs 2.6 Increased coverage of Integrated early childhood development and child protection Promote early childhood care education MGLSD MoES, DPs Promote food security and nutrition for ECD MGLSD MoES, DPs Promote child protection services MGLSD OPM, DPs promote Primary Health care, WASH and environment hygiene for ECD MoH MoES, DPs 2.7 Increased participation of the business sector Trade and Conduct a mapping exercise for the business community actors in food and nutrition MoTIC MAAIF, DP’s 72 Uganda Nutrition Action Plan 2018–2025 Intermediate Result Priority Action Lead sector Other stakeholders investment for improved nutrition Develop and implement strategy for business community actor’s participation in scaling up nutrition as per the SUN guidelines MGLSD OPM, DPs Strengthen the capacity of the business in agricultural inputs production, processing and marketing MAAIF MoTIC, DPs Support and facilitate VSLAs and SACCOs for improved access to incomes, food and nutrition MAAIF MoTIC, DPs Objective 3: Strengthen the enabling environment for scaling up nutrition specific and nutrition sensitive interventions 3.1 Functional nutrition governance at central and local government levels Enhance capacities of nutrition coordination structures at local government to coordinate, plan, implement and monitor the implementation of UNAP-II OPM DPs Enhance capacities of nutrition coordination structures MDAs to coordinate, plan, implement and monitor the implementation of the nutrition Policy and UNAP-II OPM DPs Support the implementation of the nutrition advocacy and communication strategy for UNAP II at national and local government level OPM MoLG, DPs Implement the National Family Policy to promote the rights of the family members and foster nutrition and wealth creation OPM DPs 73 Uganda Nutrition Action Plan 2018–2025 Intermediate Result Priority Action Lead sector Other stakeholders Mainstream nutrition in the Uganda women empowerment programme implementation MGLSD OPM, DPs Implement the 2015 nutrition behavioral change communication and advocacy (BCCA) strategy OPM MoLG, DPs 3.2 Improved Decision-making based on evidence generated from Nutrition research Create capacity within national institutions to operate and maintain a National Information Platform for Food and Nutrition; OPM DPs Strengthen capacity to track progress in meeting UNAP-II objectives to prevent malnutrition and monitor nutrition investments; OPM DPs Build the capacity of national policy makers, nutrition programme planners and implementers to make better use of evidence in designing and implementing nutrition-related policies, programmes and projects OPM DPs Establish the academic and research institutions network for scaling nutrition research in the country OPM MoES, DPs Establish and implement systems for mobilizing and tracking finances for nutrition in the public, private and civil society sectors OPM DPs Design and implement a monitoring, evaluation, reporting and learning plan for UNAP-II OPM DPs