National Nutrition Strategy

National Nutrition Strategy The Federal Democratic Republic of Ethiopia Federal Ministry of Health January 2008 Addis Ababa, EthioJili! The Federal Democratic Republic of Ethiopia National Nutrition Strategy Federal Ministry of Health January 2008 Addis Ababa, Ethiol2-ill J~lUliQ.llal ~.!lir.il.ioAS.traJ~gy.~Sl Table of Contents 1. Introducti on 2. Malnutrition and Its Causes 3. Statement of Purpose and Priorities 4. Objecti ve 5. Key Implementation Principles 6. Component s of the National Nutrition Strategy 7. Establishment of an Institutionalized Nutrition Coordination Body i 2 4 6 6 7 13 . ~~ti~~l N~ltitiQ~Str~~~~~Sl The extent of malnutrition in a country is determined by examining the level of chronic malnutrition (prevalence of stunting, height-for-age). The level of stunting is determined by comparing the height of a child with average height of children of the same age. The Ethiopian Demographic and Health Survey (DHS) carried out in 2005 showed that 47 percent of children under-five in Ethiopia were stunted. Similarly, 27 percent of all women of childbearing age were found to suffer from chronic energy deficiency. There are high levels of micronutrient deficiencies in Ethiopia . The adverse effects of micronutrient deficiencies on health include, but are not limited to: impaired resistance to infection , chronic fatigue, poor mental and physical development, blindness, complications in pregnancy, delivery and low birth weight. Food insecurity is not the only cause of malnutrition. Other factors such as improper feeding practices, poor child and maternal care practices, as well as social and traditional factors contribute to malnutrition. In Ethiopia, considerable progress has been made in addressing the problem of food insecurity. The Government has established rural development extension strategies and related programs to address food insecurity problems. Encouraging results have already been achieved. Similarly, strengthened efforts, focusing more on preventive services, have also been made in addressing the basic problem of health. In this regard, the recent introduction of the health extension 1 o o ~~ijQn~!N~!titiQ~St[qt~~~~~Sl program will have a far-reaching impact on the well being of the entire population. This, no doubt, will be an important step in addressing the problem of malnutrition. Although the outcomes of initiatives already implemented in the above areas are encouraging, they are not sufficient on their own as there is lack of coordination among the relevant sectors. Some of the challenges that have hindered coordination of nutrition efforts across sectors and institutions include: • Lack of a comprehensive national nutrition strategy • Lack of a national program on community-based nutrition • Lack of clear mandates and responsibilities for sectors involved in nutrition • Absence of inter-sectoral coordination and integration of activities, as well as absence of a system of sharing information and experiences • Although nutrit ion has been mainstreamed in the national development agenda, absence of a multi-sectoral coordination body • Insufficient availabi lity of nutrition professionals in the country In order to prevent malnutrition and improve the nutritional status of the population, the government has, togethe r with partners, formulated this National Nutrition Strategy (NNS). It is expected that through strengthened collaboration and coordination of efforts among all stakeholders, the National Nutrition Strategy will be successfully implemented. 2. Malnutrition and Its Causes 2.1. Types and Causes of Ma lnutrition As with most developing countries in the world, the level of malnutr ition in Ethiopia is high. The diverse, inter-linked, and complex causes of malnutrition are classified in three categories and highlighted below: 2 ~ ~ ~atiQn~l ~~!dtiQ~Strqt~~~SL 2.1.1. Immediate Causes The immediate causes are: • Low dietary intake that is either not providing the right nutrients or the required amounts of food. • Recurrent infections: the occurrence of repeated infections in children reduces their appetite and affects the bodies' ability to utilize food and further reduces resistance to infections. 2.1.2. Underlying Causes • Food insecurity: When families are unable to produce or purchase their own food or when there is unbalanced intra-household food distribution. (for example priority is often not given to children and women though they are at higher risk of malnutrition). • Lack of appropriate care: Due to negative social beliefs, attitudes, and cultural practices, children and mothers usually get less attention and care. As a result of this lack of care and reduced food intake they are exposed to malnutrition. • Lack of basic health service delivery: The unavailability or low utilization of basic health services, poor personal and environmental sanitation, and inadequate water supplies are the main causes for the prevalence of disease. Children whose health status is compromised by different infectious diseases are at greater risk of malnutrition. Similarly, children who are malnourished will have a reduced resistance to infection. 2.1.3. The Basic Causes The basic causes of food insecurity include political, econonuc, social factors, and their inter relationships. These are the major determinants in the area of food and nutrition in any country. 3 ~~tiQn~lN!~r~iQQStr~~~:~~Sl 2.2. Types of Malnutr ition • Pr ot ein ene rgy malnutrition: The main f011US of protein energy malnutrition include kwashiorkor and marasmus. These conditions mostly occur in children under-five years of age where children are greatly deprived of protein and caloric rich foods . • Micr onutr ient deficiency: The main deficiencies in this category include vitamin A deficiency, Iodine, and Iron deficiencies. Children under five years, as well as pregnant and lactating mothers are most at risk . Micronutrient defic iencies have a devastating effect on the physical and mental well being of people; however, the problem is not well recognized and micronutrient deficiencies are usually overlooked. Hence, micro-nutrient malnutrition has been dubbed: "Hidden Hunger" . 3. Statement of Purpose and Prio ri ties Malnutrition has been a serious obstacle to economic development in Ethiopia. The continuing human costs for the many malnourished people are en011JlOUS - shortened lives filled with illness and reduced physical capabili ties and compromised mental performance. It is reflected through deterioration of welfare of a population and reduction in human productivity and creativity, which are vital for the economic development of a nation. The country seeks sustainable human and econo mic deve lopment. The realization of sustainable human and economic development requires sustainable improvement in nutritional status of the population. In order to identify, prioritize and take actions, the Government of Ethiopia has formulated this National Nutrition Strategy. Although the main objective of the strategy is to ensure optimum nutrition for all citizens, it reserves focus and priorities to the following vulnerable groups: 3.1. Pregnant and Lactat ing Wo men Malnutrition during pregnancy poses a high risk for both the mother and the unborn child. In particular,. Iodine deficiency in early pregnancy can cause stillbirth and other pregnancy-related 4 ~ati~~lN~uiti~~tr~~~Sl complications. If and when the fetus is born, malnutrition can cause irreversible physical and mental defects. Similarly, iron deficiency anemia during pregnancy can increase the risk of maternal mortality and significantly contributes to low birth weight babies. 3.2. Infan ts and Childre n Under- Five Years of Age In most low-income countries, including Ethiopia, growth faltering begins in the mother's womb. The damage caused by poor nutrition in the womb or in the first years of life will be a burden that the infant/child must bear for the rest of his/her life. Rarely does a child who is stunted at age two catch up with the mental and physical growth of his/her peers. Unless, malnutrition is averted at this age, the child becomes permanently stunted. 3.3. People Living with HIV/AIDS People Living with HIV/AIDS (PLWHA) are particularly vulnerable to malnutrition due to the fact that opportunistic infections reduce appetite, reducing food intake, further exacerbating the illnesses and the progression towards AIDS. Therefore, sensitizing and educating PLWHA on the importance of maintaining appropriate nutrition is vital. 3.4. Food Insecure Households Food insecure households are vulnerable to overt and hidden malnutrition. In these conditions, children and mothers, the most vulnerable groups, and should receive special attention. 3.5. Displaced Popula tion Groups Population groups who are displaced due to either natural or man-made calamities are usually at risk. 3.6. Ot her Population Groups The elderly, prisoners, students at boarding schools, children in orphanages and hospital inpatients as well as other population groups who are exposed to malnutrition must receive adequate attention. 5 o o ~~tiQn~! ~~!QtiQQ~~~~~~~s! 4. Objective The key objective of this National Nutrition Strategy (NNS) is to ensure that all Ethiopians secure adequate nutritional status in a sustainable manner , which is an essential requirement for a healthy and product ive life. Specific obj ectives: I. To provide due attention to malnutrition vulnerab le groups of society, particularly under five children, pregnant and lactating women ; 2. To ensure the citizens are free from malnutrition related health problems; 3. To protect the society from unhealthy dietary patterns and unhealthy lifestyle that may affect their health; and 4. To coordinate and support nutritional activities of all sectors, government, non-governmental organizations and individuals working to alleviate nutritional problems. 5. Key.Implementation Principles 5.1. En suring Community Participati on Community participation will be strengthened to address local nutrition problems by including community membe rs in assessing the extent of the problems, analyzing causes, and taking actions in finding solutions. 5.2. Es tablishing and Strengthening Community Based Nut r ition Program s There will be an emphasis on mainstreaming and strengthening nutrition activities through community-based nutrition programs that contribute to the reduct ion of food insecurity and consu mption of unbalanced nutrients. The methods of tackling the underlying causes will be established and implemented through community based health and agriculture extension programs, health service delivery, education and gender programs. 5.3. Establishing an Effective Coordina tion Mechanism All concerned governmental and non-governmental organizations, as well as the partners in the private sector are expected to make unreserved contributions for the significant reduction of problems associated with food security and unbalanced nutrient consumption. 6 ~~tiQn91N»lf~i~~Sq~~gy l~~Sl 5.4. Priority for Vulnerahle Groups of the Popula tion Nutrition consideration s and interventions, particularly sustaining proper care for the nutritionally vulnerable and ensuring a healthy environment, are to be integrated with emergency response systems and will be addressed in a coordinated manner. 5.5. lmproving Nntrition Knowledge and Skills Capacity building to addre ss nutrition shall be given due consideration. Training in community nutrition is to be provided to both health and agricultural extension workers. Moreover, adequate technical and material support for carrying out nutritional intervention s will be provided to all extension staff. Due attention will also be given to strengthening higher institutions for high-level nutrition training . In addition , nutrition training programs will also be expanded. 6. Components of National Nutrition Strategy Basic nutrition intervention programs and activities which will improve the nutritional status and well being of mothers and children will be performed by various Governmental organizations in close collaboration with one another to implement the package of activities highlighted below: 6.1. Promotion of Essential Nutrit ion Actions 6.1.1. Improving the nutritional status of women • Educating and advising pregnant women to eat one additional meal in addition to their pre pregnancy meal. • Supplement pregnant women with iron/foliate tablets. • Give pregnant women de-worming tablets after their third month of pregnancy/ the first tr imester, • Educate and advise lactating mothers to have two additional meals in addition to their usual meals. • Offer vitamin A capsule to lactating mothers within the first 45 days after delivery. • Implement the strategy to alleviate micronutrient deficiencies. 7 - - --- ~ati~I~~ltiti~Str<lt~~~Sl 6.1.2. Improving the nutr itional status of children • Encourage mothers to breastfeed their children for at least two years. • Promote, educate, and encourage mothers on exclusive breastfeeding for the first 6 months and complementary food thereafter. • Educate and advise mothers on child feeding and caring practices during illness and catch-up growth. • Implement the strategy on micronutrient supplementation. 6.2. Child Growth Monitoring and Promotion Periodic, regular, weighing and measuring of children and comparisons of the results to international standards will help to assess whether their growth is appropriate. In cases of unsatisfactory growth, discussions with caregivers will be held to analyze the causes and to find solutions for the problem. Actions will also be taken to manage children affected by shortages of food and nutritional deficiency diseases due to a lack of adequate and balanced complementary foods. Preparation of appropriate and adequate complementary food from locally available sources will be encouraged. The above-mentioned nutrition activities will be implemented through the Health Facilities at various levels and largely integrated with the Health Extension Package. These activities will not be possible with the assistance of the Government alone, but will need to be implemented with the active participation of the community, which is crucial, and the cooperation of individual families. Nutrition education and promotion will be supported through appropriate teaching material s and methodologies. Additionally, improved technolo gies to save mothers' time, such as grinding mills and cooking methods among others, will be implemented . This will give more time for child feeding and caring by the mother. Availing alternative fuel sources and safe drink ing water for the community will also be encouraged. Efforts will be made to improve the status of women in the community and enhance their decision making power. 8 ~~tiQ~»l~»Diti~~~~~g~~(N~Sl 6.3. Building Knowledge, Attitudes, and Pr actices for Improved Nutr ition Knowledge is a key aspect in confronting the problem of malnutrition at all levels of society and in all sectors. Four particular aspects of knowledge transfer arc highlighted in this strategy: • Use of comm unication meth ods approp riate to bringing about behavior change: Knowledge transfer mainly focussing on parents and child caregivers with further dissemination to the community will be encouraged. This will enable families and individuals to enhance their understanding of the importance of nutrition and as a result to improve their nutritional situation. • Integrating nu tr ition in for mal education curricula: Through integrating nutrition in the school curricula, capacity-building efforts will be promoted. Pre-service and in-service training will also be given to build capacity of existing staff. • Promotion and strengthening centers of excellence for ap plied nutrition science: The government shall expand , promote, and strengthen nutrition research within potential existing centers . These research institutions will work in close collaboration with other development partners by sharing experiences. • Nutr it ion advocacy: There is often a misconception that food availab ility is equated with nutritional adequacy and better levels of nutritional status. Therefore, advocacy and promotion of nutrition education at all levels is needed to address this misconcep tion and improve nutrition. 6.4. Improving the Care and Nutritional Status of People Living With HIV and AIDS HIV has a negative impact on the household food security situation, thus lowering the nutritional status of individual s. Nutrition and HIV have strong interrelationships. Poor nutrition status speeds up the progression from HIV infection to the onset of AIDS and makes the individual vulnerable to opportuni stic infections. Adequate nutrition is critical to the efficiency of Anti-Retroviral treatments. Nutri tional counseling on improved diets and alternative mechani sms will be among the measures to address the nutritional needs of HIV infected people. HIV can be transmitted from mother-to-child through breast milk. Therefore, actions to tackle this will be implemented. 9 ~~uQn~l~p!titiQQ~jqt~~~G~~Sl 6.5 . Strengthening Nutrition in Emergencies Nutrition activities will be integrated with emergency response situations. Although there are several ways of implementing this, some of the important ones are: • Utilize nutritional data for emergency detect ion and monitoring. • Promote proper feeding practices both for lactating women and those requirin g supplementary foods during emergency situations. • Specific targeting of food aid to nutrit ionally vulnerable groups of infants, young children, pregnant or lactating women, and HIV infected people since long-term effects of poor nutrition will fall most heavily on these individuals. • Implement nutrition activities, including the health extension package, in all health facilities during emergency response. Like in non-emergency situations, moderately malnourished children shall be identified in time for supplementary feeding support. Therapeut ic feeding systems for the acutely malnourished will be strengthened. The therapeutic feeding services in place in non-emergency situations shall be redesigned to handle the increased demand related to an emergency. Community based therapeutic feeding shall also be promoted, with robust referral, monitoring and follow-up systems to support it, including in-patient therapeutic care capacity within govemment institutions. In this regard, the institutional capacities shall be strengthened. 6.6. Stre ngthening Food Security Activities The Food Security Strategy is a comprehensive prioritizat ion of the government ' s activities. The Food Securi ty Strategy contributes a great deal to the alleviation of malnutrition. Therefore, it is envisaged to strengthen the implementation of both the National Nutr ition Strategy and Food Security Strategy for better results. Agricultural Extension Workers and Health Extension Workers have an important role to play by teaching and encouraging household s to adopt , produce and consume micronutrient dense foods and animal products to complement staple food crops. Income generating activities wi ll be expanded and promoted to increase purchasing power of households. 1 0 ~~ti~~~ N»!titiQQ~tr~~gy l~~Sl . 6.7. Micronutrient Supplementation and Fortification The National Micronutrient Guidelines developed by the Ministry of Health will be followed with the implementation of micronutrient supplementation. In addition, appropriate food vehicles for fortification with iron, Vitamin A, Zinc, and other micronutrients shall be fully-utilized by both the public and private sectors. Although food fortification with micronutrients has not yet been developed due to the low-levels of industrial foods processing, special attention will be given to expanding this sector and encouraging the population to utilize industrially-processed micronutrient fortified foods. In rural areas, pilot research shall be encouraged to explore options for local fortification either within the community (such as community grain mills, where available), or in the household by providing training on basic food preparation, including the use of simple fortification products (for example using sprinkles in their cooking). All of the salt consumed in the country must be iodized. The promotion of the consumption of iodized salt, ensuring its widespread availability, and enforcing regulations restricting the use of non-iodized salt shall be implemented. Where local, small-scale production of salt renders a salt iodization strategy infeasible, alternative strategies shall be pursued to ensure that people in those areas have an adequate intake of iodine. 6.8. Food Standards Enforcement Breast-milk substitutes shall be made available and will be used when necessary. Adequate legal enforcement against unsafe promotion and use of such products shall be provided. The code of marketing of breast milk substitutes needs to be followed and proper follow-up and monitoring shall be mandatory. Food standard s shall be enforced relating to food fortification and nutritional supplements. In the case of commercially-produced and fortified products, the safety of the products shall be assured and the nutritional quality of the fortified food monitored. Legal enforcement shall be strictly 11 ~utiqn~l~~ltitiQQStr~~~~Sl implemented to avoid distribution and marketing of non-iodized salt. In order to do this, salt legislation has to be reinforced, followed-up and monitored . 6.9. Diet-Related Non-Communicable Diseases Although nutritional deficiency diseases that come as a result of shortages and unbalanced diets are prevalent in Ethiopia, overweight and obesity are also being observed. Overweight pre-disposes sufferers to various diseases such as cardiovascular diseases, obesity, diabetes, and cancer. Trends in diet-related disorders shall be monitored and appropriate action taken. In addition to this, there is a need to create awareness among the community on prevention of diet related diseases through adopting a healthy diet. 6.10. Improving Water and Sanitation Services Improving water supplies and sanitation is a' core component of both care and health services as underlying determinants of improved nutrition. A healthy environment is crucial to attaining and sustaining good nutritional status and proper growth among infants and young children in particular. Efforts to bring safe water supplies and proper sanitary facilities to all households shall be intensified in collaboration with different sectors. It is crucial to ensure their use, maintenance, and to bring about the consistent use of hygienic practices in households, especially the use of soap and regular hand washing. 6.11. Strengthening Nutrition Information System Continuous monitoring and assessment of the nutritional status of the community on a regular basis is needed to understand the depth of nutritional problems and find solutions. In addition to this, nutrition information is crucial .in evaluating the effectiveness of different nutrition intervention programs . Additional indicators of nutritional situation other than those used by the Health Management Information System will be used to monitor nutritional situations. The Central Statistical Authority conducts a Health and Demographic Survey every five years. This information will be used to assess trends and observe whether the nutritional strategy has made an impact. However, whenever additional information is needed, additional studies can be conducted. 12 )~atiQn al Nll!ritiQ.n)it!1!.t~g,y':'l1"{~ S L The Emergency Nutrition Coordination Unit and Early Warning System of the Federal Disaster Preventi on and Preparedness Agency will also be used to generate further information on nutrition. It is envisaged tha t the Integrated Diseases Surveillance and Response System, wh ich generates inform ation on diseases and their response, will be used to accommodate some nutriti on indicators that can be used in responding to emergency nutrition needs. Collaboration with other institutions and organizat ions that perfonn similar activities, other than the health sector, will be strengthened. Information flows start ing from the gras sroots to the regions and to the federal level will be facilitated and information shall be exchanged to ensure timely actions. Ope rational challenges which obstruct the Natio nal Nut rition Strategy will be ident ified through research and solutions will be found. The Ethiopian Health and Nutrition Research Institute (EHNRI) has been mandated to manage opera tional research. To do this, building the capacity of EHNR I will be enhanced. Monitoring and evaluation sha ll become part and parcel of the implementation of the National Nutrition Program, which is based on the National Nutrition Strategy. 7, Establishment of a Nutrition Coordinating Body An integ rated multi-sectoral effort is needed to alleviate the problem of malnutrition. Therefore, the Federal Ministry of Health is mandated to take the leadership role in coordinating this multi-sectoral body. The existence of this coordinati ng body will ensure the delivery of an integrated strategy at all levels and will ensure responsibility and accountab ility by the different sectors to use resources appropriately and bring about the required improvements. This body shall draw its membership from different sectors, agencies, and actors whose participation in efforts to address malnutrition is necessary. The coordinating body shall have the following responsibilities: • Leadership in coordinating all nutr ition activities in the country. The coordinating body can estab lish working groups as deemed necessary to assume this task. 13 ~~tiQn~l ~~ltitiQ~~q~~~~~Sl • Develops operational guidelines and detailed action plan s to put the strategy into practice. However, the actual planning of sectoral programs and activities within this action plan for the strategy remains the responsibility of the sectors concerned. • Develops national guidelines on implementation of the strategy by different sectors. • Follow-up, monitor and evaluate the planned nutrition activities, where needed. • Ensure that adequate budget is allocated for nutrition activities from Government, public and partners on a timely manner to continue nutrition activities. • Establish the necessary laws and legislations and monitor their practica lity. • Ensure training of adequate technical staff in the field of nutrition and their assignment in different regions. • Encourage improved service delivery and conduct operational research to optimize nutrition oriented interventions and activities. • The strategy will respond to the analysis of the nutritional conditions and the evolving nutrit ional situation. • Ensure that periodic evaluation of the National Nutrition Program is undertaken by the concerned sectors or organizations. • Document all activities and accomplishments of tile activities at all times.and produce detailed reports when necessary. 1 4