National Plan of Action for Nutrition 2021 – 2025

Lao People’s Democratic Republic Peace Independence Democracy Unity Prosperity National Plan of Action on Nutrition (NPAN) 2021-2025 1 Table of Contents Page Foreword 2 Acknowledgements 3 Executive Summary 4 List of Abbreviations and Acronyms 6 List of Figures 9 List of Tables 9 I. Context and Rationale 10 II. Purpose of NPAN 11 III. Process of Development of NPAN 12 IV. Situation Analysis 14 A. Update of Current Nutrition and Food Situation in Lao PDR 14 B. Government and Civil Society Responses 16 C. Examples of Good Practices 24 D. Summary of Review of Global Evidence to Guide the Development of NPAN 26 V. Alignment with National Policies 28 VI. Alignment with Global and Regional Guidance 30 VII. Conceptual Framework: Causes, Problem, and Consequences 32 VIII. Updated Vision, Mission, and Overall Goal of the National Nutrition Strategy and Plan of Action, and Indicators for Overall Goal 35 IX. Guiding Principles for NPAN 40 X. Strategic Framework 41 A. Components and Strategic Objectives 41 B. Interventions and Indicators by Strategic Objective 47 C. Interventions and Indicators by Sector 54 XI. Key Results by Sector 61 A. Health 61 B. Education 61 C. Agriculture 62 D. Other Sectors 63 E. Importance of Multisectoral Action 64 XII. Implementation Arrangements 65 A. National Leadership, Management, and Multisectoral Coordination 66 B. Key Actors and Partner Organizations, including Civil Society 66 C. Sub-National Prioritization, Planning, Implementation, and Monitoring 67 D. Empowerment of Communities and Primary Health Care Approach 67 XIII. Monitoring and Evaluation System and Framework 68 Annexes 75 1. Indicator Definitions 75 2. Interventions, Indicators, and Activities by Sector 94 3. Examples of Projects of Members of Scaling Up Nutrition Civil Society Alliance (SUN CSA) 109 References 111 2 Foreword The high burden of malnutrition in Lao PDR is a clear threat to achieving the Sustainable Development Goals (SDGs) and the country’s 9th National Socio-Economic Development Plan (NSEDP) of the Lao People’s Democratic Republic (Lao PDR). Lao PDR had a high stunting rate of 33% and a high underweight rate of 21% in children under 5 years of age in 2017 (LSIS 2017). Overweight is an emerging problem at 3.5% of children under 5 years of age in 2017 (LSIS 2017). Micronutrient deficiencies are prevalent, and an estimated over 70% of children under 12 months of age have anemia (LSIS 2017). Lao PDR therefore faces a triple burden of serious undernutrition, emergent overnutrition, and micronutrient deficiencies. To reduce the malnutrition and to get all peoples can access to the diversified nutritious food sources, it urges all public and private sectors at central as well as local level pay more attention and involve in implementation of nutrition interventions. Hence the quality of peoples health can be improved as well as the domestic effective workforce are built. This NPAN focuses on maternal, infant, and young child nutrition (MIYCN). At the same time, it lays out the clear links between malnutrition , food security and food systems, agriculture, education, access to health services and primary health care, adolescent health, responses to disasters and emergencies, including climate change-related events and epidemics such as COVID-19. In addition social and behavior change communication (SBCC), gender equality and the need to address nutrition from birth up to 8000 days (up to 21 years of age) and throughout the life cycle. In this NPAN, we emphasize the importance of a multisectoral approach to nutrition. This NPAN 2021-2025 features an updated and clarified conceptual framework and an updated and shortened strategic framework. There are 8 Indicators for the Overall Goal, 13 Strategic Objectives, 22 Interventions and 36 Indicators at outcome or output level. On behalf of the National Nutrition Committee of Lao PDR, I call on all multistakeholders in public and private sectors at central and local level, civil society and development partners – to work together to implement the actions outlined in this updated National Plan of Action on Nutrition (NPAN) 2021-2025 effectively. Vientiane Capital, date……./………/………… Vice Prime-Minister, Chair of National Nutrition Committee 3 Acknowledgements On behalf of the Secretariat of the National Nutrition Committee, I congratulate the Ministry of Health, Department of Hygiene and Health Promotion, Centre of Nutrition, for leading the development of the National Action Plan on Nutrition (NPAN) 2021-2025, in close collaboration with the Ministry of Agriculture and Forestry, the Ministry of Education and Sports, and other line ministries, with support from development partners and other stakeholders. We express our sincere gratitude to UNICEF, the European Union, and the World Food Programme, for technical and financial support in developing this national nutrition action plan. We acknowledge contributions from all the partner agencies and individuals who participated in the inception workshops, technical meetings, follow-up one-on-one meetings, the monitoring and evaluation workshop, and the validation meeting. These consultations were invaluable in the development of the situation analysis and in building consensus on the conceptual framework and strategic framework (Strategic Objectives, Interventions, and Indicators). Leadership and support has been provided by: • Ministry of Health, Department of Hygiene and Health Promotion, Centre of Nutrition • Ministry of Agriculture and Forestry, Department of Planning and Finance • Ministry of Education and Sports, Inclusive Education Center Participation of the members of the multisectoral Technical Working Group (TWG) on NPAN development has been essential. These agencies included the Ministry of Planning and Investment, the Ministry of Labor and Social Welfare, Lao Women’s Union, and the National Information Platforms for Nutrition project (NIPN), implemented by the Center for Development Policy Research at MPI and the National Institute for Economic Research. Other agencies who participated and provided support were USAID, the World Bank, and numerous Lao and international NGO members of the Scaling Up Nutrition Civil Society Alliance (SUN CSA). Some of the experiences of these nutrition actors are included as good practice examples in this NPAN. We express thanks to partners at provincial, district, and village, school, and community levels, including from Savannakhet, Salavanh, and Xieng Khouang provinces and others, who welcomed the NPAN development process and provided important contributions. To all of these organizations, we express our sincere appreciation and gratitude. Vientiane Capital, date……./………/………… Vice-Minister of Health, National Nutrition Committee Secretariat 4 Executive Summary Malnutrition remains a serious overall development and public health issue for the Lao People’s Democratic Republic. The purpose of this NPAN 2021-2025 is to guide the national multisectoral response to malnutrition. Conceptual Framework: The direct (immediate) causes of malnutrition are (1) inadequate nutrition intake and (2) poor access to and use of water and sanitation, poor hygiene, and diseases. The indirect (underlying) causes of malnutrition are (3) lack of availability of and access to nutritious food, (4) poor knowledge and behavior about nutritious food, and (5) poor access to health and nutrition services. The basic causes of malnutrition are (6) limitations in governance, management and coordination, (7) insufficient trained human resources, (8) inadequate health and nutrition services, (9) inadequate information system, (10) inadequate financial system, (11) vulnerability to disasters and emergencies, (12) some social norms and behaviors hinder nutrition, and (13) gender inequality. The updated Vision, Mission, and Overal Goal of the National Nutrition Strategy and Plan of Action 2021-2025 are: Vision: A prosperous country, with a healthy, food-secure population, with reduced malnutrition and poverty. Mission: Create an enabling environment to reduce all forms of malnutrition in Lao PDR, focus on nutrition priorities, and ensure effective multisectoral coordination, implementation, and monitoring and evaluation at all levels. Overall Goal: To reduce malnutrition among women and children and improve the nutritional status of all Lao people so that they are healthy and have a high quality of life, and thus contribute to the achievement of national socio-economic development targets by 2025. There are 8 Indicators for the Overall Goal: (1) stunting in children under 5 years of age, (2) wasting in children under 5 years of age, (3) underweight in children under 5 years of age, (4) anemia in children aged 6-59 months, (5) anemia in women of reproductive age (15-49 years), (6) infants born with low birth weight, (7) overweight in children under 5 years of age, and (8) infants under 6 months of age who are exclusively breastfed. Nutrition contributes to broader national health indicators. Strategic Framework: The Strategic Framwork comprises 3 Components, 13 Strategic Objectives, 22 Interventions, and 36 Indicators at outcome- and output-level. The Components are to (1) address direct (immediate) causes of malnutrition, (2) address indirect (underlying) causes of malnutrition, and (3) address basic causes of malnutrition, create an enabling environment, and promote multisectoral action. The Strategic Objectives are: (1) improve nutrient intake, (2) improve water and sanitation, promote hygiene, prevent and control diseases, (3) increase availability of and access to nutritious food, (4) improve child and adolescent knowledge and behavior about nutritious 5 diets, (5) improve mother and child health and care, (6) strengthen institutional capacity, governmance, management, and coordination, (7) strengthen human resources, (8) improvehealth service delivery system for communities, (9) improve information management and use of evidence for decision-making, (10) improve financial management and increase investment, (11) ensure effective preparedness and response to disasters and emergencies, and social protection, (12) scale up social and behavior change communication (SBCC) for nutrition, and (13) promote gender equity. This NPAN lists the 22 Interventions and 36 Indicators by Strategic Objective. It also lists the same Interventions and Indicators by responsible Sector (health, education, agriculture, and multisectoral). Of the 22 Interventions, 7 are in health, 4 in education, 4 in agriculture, and 8 are multisectoral (1 is joint between health and education and is counted only once). Of the 36 Indicators, 19 are in health, 7 in education, 4 in agriculture, and 11 are multisectoral (5 are in both health and education and are counted only once each). In addition to the three main sectors, the Multisectoral Interventions and Indicators include specific actions for the Ministry of Planning and Investment, Ministry of Finance, Ministry of Labor and Social Welfare, and Lao Women’s Union. The Annexes provide the Indicator Definitions, as well as a list of Interventions, Indicators, and Activities by Sector, including over 230 separate Activities. 6 List of Abbreviations and Acronyms ADS Agriculture Development Strategy AFN Agriculture for Nutrition Project AHAN Accelerating Healthy Agriculture and Nutrition Project ANC Antenatal care ANRCB Applied Nutrition Research Capacity Building Project APL + Association of People Living with HIV/AIDS ASEAN Association of Southeast Asian Nations BEQUAL Basic Education Quality and Access in Lao PDR Program BMS Breastmilk Substitute CANTEEN Collaboration and Networking to Enhance Education and Nutrition CDR Centre for Development Policy Research CN Centre of Nutrition CoDA Community Development Association CRS Catholic Relief Services CSO Civil society organization CU5 Children under 5 years of age DESB District Education and Sports Bureau DHHP Department of Hygiene and Health Promotion DHIS2 District Health Information System 2 DHO District Health Office DNC District Nutrition Committee DP Development partner EIA Environmental impact assessment EU European Union EU PIN European Union Programme for Improved Nutrition FAO Food and Agriculture Organization of the United Nations GALS Gender Action Learning System GDA Gender Development Association GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit (German Agency for International Cooperation) HANSA Health and Nutrition Services Access Project HIA Health impact assessment HSDP Health Sector Development Plan IEC Inclusive Education Center IFA Iron-folic acid IMAM Integrated management of acute malnutrition IMNCI Integrated management of newborn and childhood illnesses IYCF Infant and young child feeding JICA Japan International Cooperation Agency 7 LANI Lao American Nutrition Initiative LANN Linking Agriculture, Natural Resources, and Nutrition LEARN Lao Equity through Policy Analysis and Research Network LDC Least Developed Country LDPA Lao Disabled People’s association LSIS Lao Social Indicator Survey Lao TPHI Lao Tropical and Public Health Institute, Ministry of Health LWU Lao Women’s Union M&E Monitoring and Evaluation MEAL Monitoring, Evaluation, Accountability, and Learning MCH Maternal and Child Health MCNV Medical Committee Netherlands Vietnam MIYCN Maternal, Infant, and Young Child Nutrition MAF Ministry of Agriculture and Forestry MLSW Ministry of Labor and Social Welfare MOES Ministry of Education and Sports MOH Ministry of Health MPI Ministry of Planning and Investment MDD Minimum dietary diversity MODA Multiple overlapping deprivation analysis MTR Mid-Term Review NCD Non-communicable diseases NDMC National Disaster Management Committee NSEDP National Socio-Economic Development Plan NIER National Institute for Economic Research NIPN National Information Platforms for Nutrition NNC National Nutrition Committee NNSPA National Nutrition Strategy and Plan of Action NGO Non-governmental organization NPA Non-profit association NTFP Non-timber forest products ODA Official Development Assistance Oxfam Oxford Committee for Famine Relief PDES Provincial Department of Education and Sports PHC Primary Health Care PHO Provincial Health Office PNC Provincial Nutrition Committee RIES Research Institute on Education Science RMNCAH Reproductive, Maternal, Newborn, Child, and Adolescent Health RDA Rural Development Agency SAM / MAM Severe acute malnutrition / moderate acute malnutrition 8 SBCC Social and behavioral change communication SDGs Sustainable Development Goals SLP / SMP School Lunch Program / School Meal Program SO Strategic Objective SUN CSA Scaling Up Nutrition Civil Society Alliance TWG Technical Working Group UHC Universal Health Coverage UN United Nations UNESCO United Nations Educational, Scientific, and Cultural Organization UNICEF United Nations Children’s Fund USAID United States Agency for International Development USDA United States Department of Agriculture VEDC Village Education Development Committee WASH Water, Sanitation, and Hygiene WFP World Food Programme WHO World Health Organization WRA Women of reproductive age (15-49 years of age) 9 List of Figures Page Figure 1: Changes in stunting among children under 5 years of age in Lao PDR (2011 and 2017): Eleven provinces still have very high prevalence of stunting. 15 Figure 2: National and sub-national coordination mechanisms for nutrition 17 Figure 3 : Nutrition Coordination Mechanism of the Health Sector 19 Figure 4: Coordination mechanism for nutrition, Ministry of Agriculture and Forestry 21 Figure 5: Conceptual Framework for NPAN 2016-2020 33 Figure 6: Conceptual Framework for NPAN 2021-2025 34 Figure 7: Monitoring and Evaluation (M&E) Mechanism, Health Sector 69 Figure 8: Health Sector Data Flow 70 Figure 9: Monitoring and Evaluation (M&E) Mechanism, Agriculture Sector 72 List of Tables Page Table 1: Expect to target 11 indicators approved by the National Assembly 2021-2025 & 2030 36 Table 2: Indicators for Overall Goal 37 Table 3: National health indicators and annual targets to which nutrition programs contribute indirectly 38 Table 4: National health indicators and annual targets to which nutrition programs contribue directly and which are included in this NPAN 39 Table 5: Interventions and Indicators by Strategic Objective 47 Table 6: Interventions and Indicators by Sector 54 10 I. Context and Rationale 1.1. Nutrition remains one of the most important development issues for the Lao People’s Democratic Republic. Prevalence rates of maternal, infant, child, and adolescent malnutrition remain persistently high. Malnutrition is a result of poverty and poor basic socio-economic conditions. At the same time, malnutrition is a cause of poverty: malnutrition increases morbidity and mortality, drives poor physical and cognitive development, and perpetuates missed socio-economic opportunities throughout the course of life and across generations. Global estimates show that up to half of all deaths of children under 5 years of age can be attributed to malnutrition. In Lao PDR, there are an estimated 46 deaths of children under 5 years of age for every 1000 live births (LSIS 2017)1, and it is estimated that malnutrition results in an annual loss of 2.4% of GDP (Bagriansky 2013)2. It is therefore essential to invest to promote health and nutrition and to work to eradicate all forms of malnutrition, to save the lives of children, to break the cycle of poverty, and to fulfill the promise of a better future for all people in Lao PDR. 1.2. Malnutrition is a complex development issue, with multiple interrelated causes and consequences. Nutrition has to do with large, globally-influenced regional and national food systems, including agricultural production, food distribution, food security, and food safety. Schools, that reach into every community in the country, and influence the development of children, their parents and their communities, have a key role to play. Photo source: Plan International / SUN CSA in Lao PDR 1.3. Nutrition also has to do with social, economic, cultural, and gender-related beliefs and practices, which influence access to nutritious food, prevalence of disease, access to health care services, access to water and sanitation, household diets and care, and vulnerability resilience in the face of disasters and emergencies, including those related to climate change. Importantly, evidence shows that child malnutrition is directly related to maternal malnutrition, and to the health and nutrition of adolescent girls and women before marriage, during pregnancy, and during and after childbirth. At the very center of efforts to improve nutrition is reproductive, maternal, newborn, child, and adolescent health (RMNCAH), the care of pregnant women and infants in the first 1000 days (during pregnancy up to 2 years of age), promoting early and exclusive breastfeeding up to 6 months, and health, nutrition, and food choices in the first 8000 days (up to 21 years of age) and throughout the life cycle. 1.4. Because of these complex causes and consequences, it is recognized that an approach to nutrition that is focused only on the health sector is not enough. A multisectoral approach, including education, agriculture, and other sectors, is essential in 11 order to advance nutrition-specific and nutrition-sensitive interventions, addressing direct (immediate), indirect (underlying), and basic causes of malnutrition. In recent years, Lao PDR has begun the development of a “convergence” approach, whereby multiple sectors, including health, education, agriculture, and others, work together in the same geographic locations (provinces, districts, and villages) through coordinated technical approaches to influence the multiple causes of malnutrition, and drive better outcomes for families and communities. 1.5. This document provides a brief update of the National Nutrition Strategy to 2025, and a new National Plan of Action on Nutrition (NPAN) 2021-2025. It is based on the Mid- Term Review of NPAN 2016-2020 (published in 2018), data from the Lao Social Indicator Surveys 1 and 2 (2011 and 2017) and more recent research and surveys, and an extensive multisectoral multi-agency consultation process, led by the National Nutrition Committee Secretariat and coordinated by the Ministry of Health’s Department of Hygiene and Health Promotion and Centre of Nutrition, from mid-2020 to mid-2021. The purpose of this NPAN 2021-2025 is to guide the national response to malnutrition, to create an enabling environment for action on nutrition, to focus action on nutrition priorities at provincial, district, and community levels, and to promote effective multisectoral coordination and cooperation. 1.6. Since the first National Nutrition Plan (Prime Minister’s Decree 248) in 2008, the Government of Lao PDR has had a long-standing commitment, at the highest levels, to promote nutrition and to work to eradicate all forms of malnutrition. In this new NPAN 2021-2025, the government reaffirms this commitment. It calls on all sectors, Lao and international civil society organizations, and development partners, including bilateral and multilateral agencies, and the private sector, to contribute to this commitment for the betterment of all Lao people, especially women and children, and to continue to drive the country along a path towards sustainable development. II. Purpose of NPAN 2.1. The purpose of this National Plan of Action on Nutrition (NPAN) 2021-2025 is to guide the national response to malnutrition. This document provides an update of the National Nutrition Strategy to 2025, and a new National Plan of Action on Nutrition (NPAN) 2021-2025, based on the Mid-Term Review (2018), the latest data and evidence, and an extensive multisectoral consultation process held during 2020 and 2021. This NPAN articulates a mission to create an enabling environment to reduce all forms of malnutrition, to focus action on nutrition priorities, and to promote effective multisectoral coordination and cooperation. It provides indicators for the Overall Goal, Strategic Directions (renamed Components), and Strategic Objectives. These are largely unchanged from NPAN 2016-2020, with the addition of Strategic Objectives in relation to nutrition in disasters and emergencies and in the context of climate change, social and behavior change communication (SBCC), and gender equality. This NPAN 2021-2025 provides a set of 22 Interventions, replacing the 22 priority-one and 7 priority-two Interventions of NPAN 2016-2020. This NPAN provides a much smaller set of Indicators than before, 36 in all, for monitoring, evaluation, learning, and program and policy improvement. 12 2.2. The aim is that each sector, in particular the key sectors of education and agriculture, will further integrate nutrition into its own sectoral strategy and plan. Each province and district, through their provincial and district nutrition committees, will develop and implement annual operational plans for nutrition based on this NPAN. It is expected that each provincial and district plan will be multisectoral, including and highlighting cooperation across sectors in order to address cross-cutting issues. This NPAN also aims to guide Lao and international civil society organizations (CSOs), bilateral and multilateral development partners, and all other stakeholders, including the private sector, in developing nutrition-specific and nutrition-sensitive interventions, funded by government, official development assistance (ODA), and other sources. 2.3. This NPAN is multisectoral. Strategic Objectives, Interventions, and Indicators are clearly labelled as being the responsibility of one or more sectors. One of the key aims of this NPAN is to foster and promote more effective, better-quality coordination and cooperation across sectors. In earlier years, Lao PDR had limited nutrition coordination mechanisms. As a mark of progress, these now currently exist at national, provincial, and district levels. But in the period of this NPAN, 2021-2025, it is critical that these coordination mechanisms function better than before, and generate results leading to more effective delivery and greater impact of nutrition interventions. 2.4 It is only by working across sectors, at all levels, addressing the complex, interrelated causes of malnutrition, that Lao PDR will be able to make true progress to promote nutrition and to work towards the elimination of all forms of malnutrition. This NPAN aims to provide direction and guidance. III. Process of Development of NPAN 3.1. Under the leadership of the National Nutrition Committee and the Ministry of Health, the Department of Hygiene and Health Promotion (DHHP) and the Centre of Nutrition took the lead in the development of this NPAN, working collaboratively with the Ministry of Education and Sports, Ministry of Agriculture and Forestry, Ministry of Planning and Investment, Ministry of Labor and Social Welfare, the Lao Women’s Union, other government agencies, the Scaling Up Nutrition Civil Society Alliance (SUN CSA) and its Lao and international civil society members, and bilateral and multilateral development partners. Initial meetings were held in mid-2020. 3.2. The Department of Hygiene and Health Promotion and Centre of Nutrition obtained support from UNICEF, and the education and agriculture ministries obtained support from the World Food Programme (WFP), in the form of consultants to work with the various sectors to develop this NPAN. The consultant team was led by the former Director-General of DHHP and included an international consultant as strategic plan writer. The team conducted a rapid review of global, regional, and national sectoral reviews and relevant materials and conducted an extensive consultation process during September-December 2020. 13 3.3. The consultation process began with a briefing for the Vice-Minister of Health and, during September 2000, four national-level inception meetings, each with: (1) various relevant health departments and centers, (2) different ministries, (3) development partners (UN agencies and donors), and (4) civil society organizations. The inception meetings were followed by one-on-one meetings with different organizations as required. Site visits were conducted to Khammouane, Savannakhet, Sekong and Xieng Khouang provinces in September-December 2020, including visits to some districts, villages, and schools. Consultants working with the education and agriculture ministries conducted separate site visits. 3.4. With support from the World Food Programme (WFP), the education sector conducted an end-line evaluation to review sectoral responsibilities under the NPAN 2016- 2020, and to develop a strategic shift for the sector for NPAN 2021-2025. Methods included document review, broad stakeholder interviews at central and local levels, and field observations in Bokeo and Oudomxay provinces in September 2020. 3.5. An initial multisectoral technical working group meeting and stakeholder consultation was held in mid-November 2020, and an initial development partners’ group meeting was held in mid-December 2020, to present and discuss the key findings and recommendations; updated Vision, Mission, and Goal; and updated Components, Strategic Objectives, Interventions, and Indicators. The initial draft of the NPAN was developed based on these meetings. These meetings were opportunities to underline the need for more sectoral discussions on the Interventions and Indicators, before the development of the NPAN Monitoring and Evaluation Framework. 3.6. The European Union (EU) and UNICEF, working with the Ministry of Planning and Investment (MPI), Centre for Development Policy Research (CDR), commissioned a review of the costing of the previous NPAN 2016-202014. The main recommendations focused on structural, process, content, and implementation challenges of the previous NPAN budget. In particular, it highlighted the importance of the involvement of the Ministry of Finance in developing a realistic nutrition budget whose components should form part and parcel of sectoral budgets. Based on this review, a separate costing exercise of this NPAN 2021-2025 will be designed and conducted. 3.7. With support from the European Union (EU) and the World Food Programme (WFP), the agriculture sector conducted a series of internal meetings to develop the agriculture section of this NPAN (Strategic Objectives, Interventions, Indicators and Activities). This culminated in a national consultation for agriculture for nutrition, held in Vang Vieng, Vientiane Province, in late March 2021. 3.8. The draft NPAN 2021-205 was further discussed and improved at various meetings, including at the National Nutrition Forum in February 2021, the Department of Hygiene and Health Promotion national strategy meeting in March 2021, and at an NPAN Monitoring and Evaluation Consultation meeting in April 2021. Multiple sector-specific meetings were organized by the Ministry of Health, Ministry of Agriculture and Forestry, and Ministry of Education, during January-May 2021. The National Committee for NPAN Development considered and validated the draft at a Validation Meeting in Vientiane Capital in June 2021. 14 It is expected that the National Nutrition Committee will accept and endorse the final version, incorporating revisions after validation, during its next regular meeting. IV. Situation Analysis A. Update of Current Nutrition and Food Situation in Lao PDR 4A.1. The population of the Lao People’s Democratic Republic was estimated at 7.3 million people in 2020 (World Bank 2021)3. Lao PDR is divided into Vientiane Capital and 17 provinces. In recent years, Lao PDR has experienced rapid economic growth, driven by regional economic integration and trade with its neighbors, particularly Thailand, China, and Viet Nam. However, growth dipped from 6.3% in 2018 to 4.8% in 2019 (World Bank 2020)4. In 2020, the COVID-19 pandemic and response intensified this slowdown, with growth declining to -0.6% (World Bank 2021)5. As a result of the pandemic, 70% of households reported being affected by rising food prices, and 37% have reduced their food consumption (World Bank 2021)5. In Lao PDR, as in countries around the world, the pandemic is expected to have a negative effect on nutrition, especially among the most vulnerable, because of socio-economic vulnerability (CDR 2021)6 reduced household income, reduced access to nutritious food, and disruptions to nutrition-related services (JME 2021)7. 4A.2. In recent years, Lao PDR has made progress in improving population health: life expectancy was 66 years for males and 70 for females in 2019 (WHO 2019)8. However, public spending on health and access to health insurance remain low, and health shocks remain a factor for households falling back into poverty (WHO 2017)9. The maternal mortality ratio remains high at 185 per 100,000 births, and only 38% of births in rural areas occur in a health facility (LSIS 2017)1. Communicable diseases remain a problem while non- communicable diseases continue to increase, with negative effects on maternal and child health (WHO 2017)9. 4A.3. In the period before COVID-19, there has been a general improvement in nutrition in Lao PDR: stunting in children under 5 years has decreased from 44% in 2011 to 33% in 2017 (LSIS 2017)1. This rate, however, is still very high, and efforts are needed to reduce stunting further. In addition, wide provincial disparities have become evident: Vientiane Capital has medium prevalence of stunting at 13.8%; some provinces in central Laos, such as Bolikhamxay, Khammouane, and Savannakhet, have high prevalence of stunting; most provinces in northern Laos and some in southern Laos, including Salavanh and Sekong, have very high prevalence of stunting; and the highest prevalence of stunting was in the northern province of Phongsaly, at 54% (NIPN 2020)10. Eleven out of 18 provinces still have very high prevalence of stunting (NIER NPIN 2019)11. As noted in the Mid-Term Review of the National Nutrition Strategy and Plan of Action (2018), malnutrition has become most prevalent in remote, rural settings that are hardest to reach. 15 Figure 1: Changes in stunting among children under 5 years of age in Lao PDR (2011 and 2017): Eleven provinces still have very high prevalence of stunting. 2011 2017 Source: National Information Platforms for Nutrition (NIPN) (2020) Lao PDR National Nutrition Profile 4A.4. Underweight in children under 5 years has decreased from 27% in 2011 to 21% in 2017 (LSIS 2017)1. Measured percentage of low birth weight was 6.5% in 2017 (LSIS 2017)1. However, acute malnutrition (wasting) in children under 5 years has increased from 6% in 2011 to 9% in 2017 (LSIS 2017)1, with high or very high prevalence of wasting in the provinces of Savannakhet, Salavanh, and Attapeu (NIPN 2020)10. Overweight is an emerging problem at 3.5% in 2017 (LSIS 2017)1, with prevalence of overweight over 5% in Vientiane Capital and some northern provinces (NIPN 2020)10. 4A.5. Maternal malnutrition, which is a key determinant of child malnutrition, continues to be a problem: 40% of women of reproductive age (15-49 years) have anemia (above the WHO recommended threshold of 20%), 12.8% are overweight, and 3.5% obese (NIPN 2020)10. About half of all pregnant women are estimated to have anemia, as do over 70% of children under 12 months of age (LSIS 2017)1. 4A.6. The immediate (direct) causes of child under nutrition include poor maternal nutrition and poor infant and young child feeding (IYCF) practices, i.e., lack of early, exclusive breastfeeding up to 6 months and continued 53.2 Bokeo Luangprabang Huaphanh 39.0 Xiengkhuang 52.9 Xaysomboune 19.3 Vientiane Cap. 41.0 <2.5% 41.0 2.5 - <10% Low prevalence 10.0 - <20% Medium prevalence 54.4 Sekong 62.7 > 30% Very high prevalence Champasack No data 36.7 Values for Lao PDR 34.1 41.3 40.0 33.0 % [2017] Xiengkhuang 46.3 Vientiane Prov. 44.0 33.0 Borikhamxay 29.9 13.8 42.9 Sekong 49.9 Champasack 24.6 16 breastfeeding up to 2 years or more; insufficient dietary diversity; and prevalence of communicable diseases related to insufficient access to and use of clean water, sanitation and hygiene (WASH). Photo source: Plan International / SUN CSA in Lao PDR 4A.7. Among infants under 6 months of age, the proportion receiving exclusive breastfeeding is 44% (LSIS 2017)1. For children under 2 years of age, the proportion receiving a minimum acceptable diet was 26.5% in 2017, with higher rates associated with urban setting, higher household income, and higher mother’s education (LSIS 2017)1. The highest-priority nutrition-specific interventions include improving maternal nutrition and IYCF practices, improving nutritious diets, iron-folic acid (IFA) and other micronutrient supplementation, and deworming. WASH interventions require investments in both infrastructure as well as social and behavioral change communication (SBCC) (MTR 2018)12. Integrated management of acute malnutrition (IMAM) remains an important issue related to integrated management of newborn and childhood illnesses (IMNCI) and overall access to integrated health and nutrition services at the community level. 4A.8. The underlying (indirect) causes of child undernutrition include lack of availability of and access to food, chronic and acute seasonal household food insecurity, the high cost of nutritious diets, poor mother and child care practices, limited access to health care, particularly antenatal care, and poor water and sanitation systems. Nutrition-sensitive interventions include improving household food security, improving education about nutrition and related school-based interventions, and improving the socio-economic status of women and promoting gender equality. Food security and school-based interventions require involvement of agriculture, education, and related sectors and agencies. Food insecurity is also affected by vulnerability to natural and human-made disasters and emergencies, including climate change-related events such as droughts and floods. 4A.9. The basic causes of child malnutrition include poverty, insufficient human resources, investment, information, insufficient institutional responses, coordination and linkages. Continued progress requires sustained political commitment and effective governance at national, provincial, district and community levels, and improved implementation, monitoring and use of data, service integration, and multisectoral cooperation. Interventions should focus on common priority geographical locations and coordinated technical approaches to address multiple interrelated determinants of malnutrition simultaneously (Convergence 2019)13. B. Government and Civil Society Responses 4B.1. Governance and coordination. The National Nutrition Committee (NNC) was established in 2013 and is chaired by the Deputy Prime Minister. Key sectors in the response, the Ministry of Health, Ministry of Agriculture and Forestry, and Ministry of Education and Sports, were designated in 2016. Similar provincial, and district-level multisectoral coordination mechanisms, provincial and district nutrition committees (PNCs/DNCs) have been established, and are in general operational. The role of the Centre of Nutrition, within the Health Ministry’s Department of Hygiene and Health Promotion, is to provide technical direction and coordination for nutrition service delivery and 17 programming nationwide. The Centre of Nutrition provides support to the National Nutrition Committee Secretariat, and in addition it serves as the National Center of Excellence on Education and Research on Nutrition. Figure 2: National and sub-national coordination mechanisms for nutrition Source: Lao National Nutrition Committee (NNC) Secretariat (2019) Operational Guidelines for Multisectoral “Convergence” Approach to Nutrition 4B.2. Implementation and human resource capacity. Implementation of nutrition-specific interventions is primarily through small hospital (health center) staff at the community level, providing nutrition education, counselling, and services as part of the broader package of reproductive, maternal, newborn, child, and adolescent health (RMNCAH) services. Small hospital staff are assisted by village health committees and village health volunteers; are trained, supervised, and supported by health staff at district and provincial levels; and work in coordination with education and agriculture staff at the respective levels (village/community, district, and province). In locations with projects supported by official development assistance (ODA) implemented by Lao and international civil society organizations, project staff work closely with government counterpart staff. At the national level, the Department of Hygiene and Health Promotion (DHHP) and the Centre of Nutrition conduct training and supervision of nutrition teams at provincial and district levels. ODA projects also provide financial support for DHHP and NC management, training, and supervision functions. 18 4B.3. Financing and sustainability. Financing of nutrition programs is dominated by official development assistance (ODA), which accounted for 90% of nutrition spending during 2016- 2019 (Kurtishi 2020)14. This leads to a particular challenge for nutrition interventions in Lao agencies or NGOs, have very little government budget for nutrition, and may conduct very few nutrition-specific actions, if any. On the other hand, districts and villages with ODA support do have a range of nutrition-specific and nutrition-sensitive activities, but, once ODA ends, they are not likely to be able to sustain these actions. Multisectoral actions, for example, those combining WASH, nutrition education, and agricultural extension in a single village or group of villages in a district, face particular difficulty to be sustained with government funds, which flow primarily by sector. 4B.4. Analysis of the response. The National Nutrition Committee, in its half-year meeting held on July 2020, identified the following continuing challenges in the nutrition response: • Insufficient integration across sectors, particularly between health and agriculture; • Implementation challenges with health in schools: lack of water in schools, some allergic reactions to deworming; • Challenges in understanding and implementing the new EU mechanism of direct budget support for nutrition; • Implementation challenges due to COVID-19; • Insufficient staff with knowledge and capacity; • Challenges in regular nutrition monitoring and timely reporting; and • Challenges in gathering and analyzing reports from NGO projects for coordination and program improvement. This NPAN directly addresses the challenges above, in particular integration and multisectoral cooperation, human resource capacity, and monitoring and reporting capacity, through various Strategic Objectives. By sector 4B.5. Health is the leading sector for the nation nutrition program. The nutrition strategy sits within the broader strategy for reproductive, maternal, newborn, child, and adolescent health (RMNCAH). Both the Centre of Nutrition and the Center for Maternal and Child Health sit within the Department of Hygiene and Health Promotion (DHHP), Ministry of Health. Photo source: Plan International / SUN CSA in Lao PDR 19 Figure 3 : Nutrition Coordination Mechanism of the Health Sector 4B.6. Of the 11 top-level national health indicators regularly reported by the health ministry to the National Assembly, two are nutrition-specific: stunting and underweight, both among children under 5 years of age (of the other top-level indicators, 4 are related to maternal and child health, 1 to immunization, 2 to water and sanitation, 1 to health insurance, and 1 to health model villages). Nutrition services are provided through integration with services for maternal and child health, immunization, antenatal care and safe motherhood, family planning, and water, sanitation and hygiene (WASH). The Health Sector Reform Strategy emphasizes the importance of integrated delivery of Primary Health Care (PHC) at the community level, as a cornerstone of Universal Health Coverage (UHC). Within this, the Community Health Systems Strengthening Action Plan outlines the implementation of community based PHC targeting the most vulnerable populations for health and nutrition equity. The Health Sector Development Plan (HSDP) 2021-2025 identifies the importance of continuing investment in human resources for health, including health staff, village volunteers, and village health committees, as well as improving the quality of monitoring and evaluation, through the District Health Information System 2 (DHIS2). 20 4B.7. Education. As it reaches the mass of school-age children, and involves their parents and communities, the education sector has a critical role to play in the nutrition response. Within the Ministry of Education and Sports, the Inclusive Education Center (IEC) serves as the secretariat for the ministry’s nutrition committee, which involves a range of departments and units. Photo source: Dr Kiengkay Ounmany, SEAMEO Regional Centre for Community Education Development, Ministry of Education and Sports 4B.8. In the period 2016-2020, the education sector has been responsible for 4 nutrition measures, including integration into the curriculum, school meals (school lunches), school gardens, and health interventions, such as iron-folic acid supplementation and deworming, implemented in schools. As noted above, the education sector has conducted an end-line evaluation of its contribution to NPAN in 2020. The sector continues to receive support from agencies such as the US Agency for International Development (USAID), the US Department of Agriculture (USDA), the World Food Programme (WFP), and Catholic Relief Services (CRS) for its school meal program (SMP) and the construction of school toilets. The ministry’s plan is to expand the SMP nationwide. 4B.9. Coordination within the education sector: The Vice-Minister of Education and Sports appointed a task force for coordination on nutrition in early 2018. The task force members include senior officials from the Department of Planning, Department of Early Childhood Education, Department of General Education, Department of Teacher Education, Department of Non-Formal Education, the Research Institute on Education Sciences (RIES), and the Inclusive Education Center (IEC). Partners include the World Food Programme (WFP), the BEQUAL program, Catholic Relief Services (CRS), JICA, GIZ, UNESCO, UNICEF, and the World Bank. 4B.10. Agriculture. Responsible for oversight and development of agricultural production, the agriculture sector likewise has a critical role in the nutrition program, as people require sufficient access to food. Within the Ministry of Agriculture and Forestry, the Department of Planning and Finance serves as the secretariat for the ministry’s nutrition committee, which, like its education counterpart, also involves a number of departments and units. In the period 2016-2020, the agriculture sector has been responsible for 4 nutrition-sensitive measures, including production of plant- and animal-based foods, post-harvest processing and preservation, and support for income generation. However, the 2018 Mid-Term Review found that it was not possible to track the set indicators, and so the ministry developed a revised set of measures and indicators, adding the development of nutrition-sensitive value 21 chain, and participatory village planning and management of natural resources, including non-forest timber products (NFTP) and small infrastructure. Photo source: Plan International / SUN CSA in Lao PDR 4B.11. As noted above, the sector has invested a signficant amount of time and effort in the development of the agriculture part of this NPAN. The sector has received support from the European Union (EU), the Food and Agriculture Organization (FAO), and various non- governmental organizations (NGOs). The Ministry of Agriculture uses an internal coordination mechanism for coordination on nutrition matters. Figure 4: Coordination mechanism for nutrition, Ministry of Agriculture and Forestry 4B.12. Convergence. The National Nutrition Committee initiated discussion of the multisectoral convergence approach in late 2013 and adopted operational guidelines in 2019. Through the convergence approach, the government of Lao PDR encourages and promotes common geographical targeting and technical coordination, so that different sectors (primarily health, education, and agriculture) deliver a variety of nutrition-specific and nutrition-sensitive services and support in the same geographic locations (districts and villages) towards common goals. Some interventions already have nationwide coverage (for example, vitamin A supplementation and deworming for children under 5 years of age) or are intended for nationwide scale-up (for example, the School Meal Program). However, many interventions need to be targeted, based on need. Common targeting should address multiple causes of malnutrition simultaneously, improving the likelihood of positive impact. Notable examples of the convergence approach in action include the World Bank’s support to the nutrition program in 4 northern provinces (Phongsaly, Oudomxay, Houaphanh, and Xieng Khouang) through the Health and Nutrition Services Access Project (HANSA) and other projects, and World Vision’s AHAN project, supported by the European Union’s Programme 22 for Improved Nutrition (EU PIN). AHAN aims to provide integrated programming addressing dietary and care practices, WASH, gender equity, access to food, and multisectoral coordination in 3 provinces (Savannakhet, Salavanh, and Attapeu). However, one challenge to convergence is that the key sectors – health, education, and agriculture – all have different priority districts for action. Convergence should ensure attention both to sectoral priorities as well as nutrition need (high rates of malnutrition) and potential for impact. The National Information Platform for Nutrition’s (NIPN) recent (2019) analysis of multiple dimensions of child poverty provides insight that will be useful for continued multisectoral targeting and convergence. 4B.13. Social and Behavior Change Communication (SBCC) strategy. The National Nutrition Strategy to 2025 recognized the importance, within each sectoral approach, of social and behavioral change communication (SBCC) to promote nutrition. Communication is essential within each sector. For example, within health, iron-folic acid (IFA) and vitamin A supplementation and deworming require successful campaigns. In schools, education about nutrition and the importance. For workers in the agriculture sector, it is important to communicate not only about methods to increase agricultural production, but also to promote household access to food and effective dietary choices and practices. The National Nutrition Committee adopted the Nutrition SBCC Strategy in 2018. The SBCC Strategy recognizes SBCC as a professional field of expertise. Its objectives are to: enhance nutrition behaviors, enhance the enabling environment, and enhance capacity for nutrition SBCC. It outlines communication approaches for addressing nutrition across all sectors, focusing specifically on key messages about maternal nutrition, infant and young child feeding (IYCF), and water, sanitation and hygiene (WASH). This NPAN further elevates the important role of social and behavioral change communication (SBCC) by including it at the Strategic Objective level. Monitoring and Evaluation 4B.14. Government Systems. Nutrition monitoring and evaluation (M&E) requires the use of systems across sectors. In the health sector, responsibility for nutrition M&E lies with the Centre of Nutrition, within the Department of Hygiene and Health Promotion (DHHP), in cooperation with the Department of Planning and Cooperation (DPC). The health sector uses the District Health Information System 2 (DHIS2), which captures some key nutrition indicators. 4B.15. Common Results Framework. Within NPAN 2016-2020, efforts were made to develop a multisectoral Common Monitoring and Evaluation Results Framework. The draft Framework provides detailed indicator definitions for NPAN. However, it remained incomplete, because only health sector indicators were agreed. This NPAN 2021-2025 provides an updated M&E framework in Section 13 and Annexes below. 4B.16. National Information Platforms for Nutrition (NIPN). In 2018, Lao PDR began participating in the multicountry initiative National Information Platforms for Nutrition, supported in a number of countries by the European Union, UNICEF and other donors. In Lao PDR, the NIPN project has 2 components -- data, implemented by the Ministry of Planning and Investment’s Centre for Development Policy Research; and policy, 23 implemented by the National Institute for Economic Research – both working in cooperation with relevant ministries and partner organizations. NIPN has become a rich source of data and analysis for the national nutrition program, having published the latest nutrition profile, data mapping, capacity needs assessment, policy landscape assessment, and multiple overlapping deprivation analysis (MODA). The project has recently been extended for 3 more years, to 2024. One key priority is to ensure that NIPN’s strategic information products and capacities are adopted and absorbed by national nutrition actors, so that these remain sustainable after the project ends. 4B.17. Other sources. Many nutrition projects conduct research and generate strategic information to guide program and policy development. Notable examples include World Vision’s AHAN project and MCNV’s CANTEEN and LEARN projects, which are all supported in full or in part by the European Union’s Programme for Improved Nutrition (EU PIN). These projects have worked with the Lao Tropical and Public Health Institute (Lao TPHI) among others, and generated numerous research and policy studies published in the global peer- reviewed literature Another example is the Rural Development Agency’s (RDA) assessment of school-based initiatives in water, santiation, and hygiene (WASH) and school gardens. CRS’ Applied Nutrition Research Capacity Building (ANRCB) and the Lao American Nutrition Initiative (LANI) funded by USAID work with the Center of Nutrition, LaoTPHI, and UHS to improve capacity to conduct and utilize nutrition research in Lao PDR. They have outfitted rooms at the Center of Nutrition to support these training needs focusing on anthropometry, basic nutrition, and research methods for academic and central level practitioners. 4B.18. Scaling Up Nutrition Civil Society Alliance (SUN CSA). Lao PDR joined the global Scaling Up Nutrition (SUN) Movement in 2011. The Centre of Nutrition serves as the focal point of SUN Laos. The Scaling Up Nutrition Civil Society Alliance (SUN CSA) is a network of over 70 Lao and international civil society organizations working to support the nutrition efforts of the government of Lao PDR. In 2020-2021, SUN CSA member organizations implemented 55 projects in 16 provinces of Lao PDR, reaching over 1 million people. The projects focus on health, education, agriculture, WASH, women’s empowerment, and multisectoral coordination. SUN CSA has 5 core functions: building technical capacity of member organizations; acting as a nutrition knowledge hub; supporting effective nutrition policy; building partnerships for nutrition action; and maintaining a collaborative network. Many NGO projects are multisectoral by design and in implementation, with local (district and village-level) actions planned and implemented across sectors. Annex 3 provides examples of nutrition-related projects implemented by members of SUN CSA. 4B.19. A key focus of SUN CSA member organizations is to deliver local solutions to address nutrition disparities, in particular during the first 1000 days (during pregnancy up to 2 years of age), emphasizing the importance of maternal nutrition, and early and exclusive breastfeeding. SUN CSA members working at the national level include PLAN International and Save the Children International. Lao civil society members include APL+, CoDA, GDA, LDPA, and many others. Starting in 2020, SUN CSA members have implemented activities responding to COVID-19, including development of new information materials on nutrition and breastfeeding during the pandemic. 24 4B.20. According to the Mid-Term Review (2018), moving forward, the key next steps for the national nutrition response are to: more effectively prioritize nutrition interventions within sectors (health, education, and agriculture); address bottlenecks and improve the quality and effectiveness of multisectoral coordination; use new evidence generated from LSIS 2, NIPN, and other strategic information sources to improve planning and service delivery; and improve the common multisectoral monitoring and evaluation results framework. C. Examples of Good Practices 4C.1. The following are examples of noteworthy practices in the implementation of the National Nutrition Strategy. These examples support the government response; build human resource and program implementation capacity at the local level; apply multisectoral, convergence, and social and behavior change communication (SBCC) approaches; and contribute to improved monitoring and evaluation (M&E) for nutrition. There is space for only few examples, and some that were shared during the consultation process for this NPAN could not be included. A longer list of examples from SUN CSA is in Annex 3. Example 1: Methods to Address Causes of Malnutrition at the Community Level by SUN CSA Member Organizations and Government Partners Both LANN and GALS are integrated, participatory methodologies to engage with people at the village/community level and to address nutrition and gender. LANN stands for “Linking Agriculture, Natural Resources, and Nutrition.” The approach consists of 8 village sessions, for government staff, civil society, and village volunteers, implementing integrated agriculture, natural resource management, health, hygiene, and nutrition programs. GALS stands for “Gender Action Learning System.” It is a series of participatory activities that allows women and men, in families, groups and communities, to discuss and explore their actions and workloads and plan for their future. Both LANN and GALS have been adapted by Lao nutrition practitioners to the context of Lao nutrition and food security, and so are practical and specific to the Lao context. Example 2: World Bank’s Support for Lao PDR’s Convergence Approach in Four Northern Provinces The World Bank is prioritizing investment in four northern provinces with some of the highest prevalence of stunting in the country -- Phongsaly, Oudomxay, Xieng Khouang, and Houaphanh – initially in 12 target districts. In these locations, the aim is to support the country’s multi-sectoral convergence approach to nutrition. Various projects are phased, starting with building and strengthening the institutional foundations for multi-sectoral interventions, and, once there is evidence generated about what works, using this to expand program coverage. Among the projects is the Health and Nutrition Services Access (HANSA) Project. Across a range of projects, interventions include: iron-folic acid (IFA) for pregnant women; vitamin A for children under 5 years of age; growth monitoring for children under 2 years of age; social and behavioral change communication (SBCC) conducted by trained female village volunteers; improving water sources, supply systems, and sanitation; improving use of latrines and handwashing; and elimination of open defecation. These 25 projects are implemented by different ministries and government agencies, working in the same geographical locations. It is therefore recognized that effective implementation requires strong national, provincial, and district ownership and leadership. In order to use the funds effectively, implementing partners need investment in institutional capacity for coordination, as well as strong monitoring and evaluation systems and skills. Example 3: Integrated Nutrition Programming in World Vision and Partners’ AHAN Project World Vision leads the Accelerating Healthy Agriculture and Nutrition (AHAN) Project with a consortium of partners; the project period is 2019-2021 and the budget is Euro11 million from the European Union’s Programme for Improved Nutrition (EU PIN), with complementary funding from Australia. The project works in 3 provinces, Savannakhet, Salavanh, and Attapeu, in a total of 12 districts, and 120 villages (10 villages per district). The AHAN project recently released the results of a qualitative study on feeding practices affecting maternal and child nutrition (2020). Among its recommendations are to: • Prioritize maternal and child nutrition outcomes, • Implement specific strategies to support breastfeeding, • Develop specific messages for nutrition education, • Address gender power relations and support fathers’ contribution to maternal and child nutrition, • Address food choices, food taboos, and food insecurity, • Implement home gardens to support dietary diversity, • Manage positive and negative impacts of commercial food exchange, • Respond to increasing accessibility of highly processed foods, • Support village health staff and volunteers, and • Build on existing successes and assets. These recommendations require project staff, volunteers, and partners to work effectively across sectors, as well as staff and volunteers who are able to conduct effective social and behavior change communication (SBCC) for nutrition. Example 4: A Lao NPA Making a Difference in Nutrition: CoDA in Savannakhet Province Community Development Association (CoDA) is a Lao non-profit association (NPA) which was founded in 2005, based in Savannakhet Province, and which works in the agriculture, education, and environment sectors. It implements a number of nutrition projects in the districts of Nong, Thapangthong, and Xonnabouly districts, partnering with international NGOs such as MCNV, Oxfam, and PLAN International, with funding from the EU and GIZ. CoDA’s nutrition work focuses on improving maternal and child nutrition with a focus on the first 1000 days of life (during pregnancy up to 2 years of age). Central to this is social and behavioral change communication (SBCC) activities to promote positive attitudes and dietary behaviors. CoDA is an active member of the Scaling Up Nutrition Civil Society Alliance (SUN CSA). CoDA uses the Linking Agriculture, Natural Resources, and Nutrition (LANN) and Gender Action Learning System (GALS) methods, described above. As a result of its work in project villages, CoDA reports improvements in exclusive breastfeeding, maternal and child dietary diversity, supplemental feeding, home gardening, fathers’ involvement, women’s decision-making, and access to health services. Continuing challenges include poor access to antenatal care, poor rate of facility birth, periodic food insecurity and inability to purchase food, and poor use of latrines and handwashing. 26 D. Summary of Review of Global Evidence to Guide Lao PDR NPAN 4D.1. UNICEF Lao PDR recently commissioned a summary review (2020) of global nutrition evidence with particular relevance for development of this NPAN 2021-2025. The most important key findings and recommendations include: 4D.2. Mid-Term Review. The Lao PDR NPAN 2016-2020 Mid-Term Review (2018) noted that some activities need better articulation. The MTR found there was a need to use evidence, prioritize and focus interventions, and address bottlenecks to coordinated multisectoral implementation, in particular in nutrition-sensitive interventions in the education and agriculture sectors. 4D.3. Maternal nutrition and sanitation as major drivers. Global evidence shows that the largest stunting burden is associated with poor maternal nutrition, poor pregnancy outcomes including preterm birth and low birth weight, and unimproved sanitation. In Lao PDR, it is urgent to improve maternal and WASH outcomes. While nutrition interventions should continue to center on infants and young children, they should also reach women before pregnancy, during pregnancy and breastfeeding, and focus on promoting clean, hygienic living environments. 4D.4. NPAN 2016-2020. The structure of NPAN 2016-2020 is fundamentally sound, and this NPAN 2021-2025 should further make it clearer: one Component to focus on nutrition- specific interventions, largely implemented by the health sector; one Component to focus on nutrition-sensitive interventions, such as improved access to food, education, and health services, implemented by health and other sectors; and one Component to focus on engaging and coordinating multiple sectors to create an enabling environment. 4D.5. First 1000 days of life. Priority nutrition interventions should continue to focus on reaching women and children during the first 1000 days of life (during pregnancy up to 2 years of age), the critical window of opportunity for improving nutrition. Interventions should include dietary counselling and nutrition screening, with supplementary feeding for the undernourished. Cultural taboos should be addressed, as part of the National Nutrition Social and Behavior Change Communication (SBCC) strategy. Small hospital staff and village health volunteers should receive training and supervision for nutrition counselling. Micronutrient supplementation should focus on Vitamin A and iron-folic acid (IFA) supplementation, with deworming as an important associated intervention. Nutrition education is particularly important for adolescent girls, as early marriage and childbearing is common in Lao PDR. Nutrition programs should be situated within the broader strategy for reproductive, maternal, newborn, child and adolescent health (RMNCAH), and contribute to efforts to improve family planning and antenatal care (ANC). 4D.6. Child nutrition. Interventions for child nutrition should include: breastfeeding promotion; counselling for complementary feeding for 6-24 months; Vitamin A supplementation; deworming; integrated management of newborn and childhood illnesses (IMNCI); and treatment for wasting. Lao PDR has made considerable progress in early initiation of and exclusive breastfeeding, but the coverage of nutrition services for children under 5 years of age remains low, and large-scale multi-channel social and behavior change 27 communications (SBCC) for maternal and child health and nutrition have yet to be implemented. 4D.7. WASH. Unsafe water and unimproved sanitation leading to diseases continue to be important drivers of undernutrition. Interventions to address this issue should include: improvement of water supply and household water treatment; access to and use of improved sanitation facilities; and hygiene, including handwashing. Global evidence shows that water, sanitation, and hygiene (WASH) interventions do not improve nutrition outcomes when implemented as standalone projects, but they do deliver outcomes when delivered at high coverage (reaching over 75% of affected communities), over an extended period (up to 5 years), integrated across health and development programs for the same community, and targeting families with infants (under 2 years of age). In Lao PDR, the health sector continues to be responsible for the development of WASH in rural areas, while the public works sector is responsible in urban areas. Existing WASH interventions in Lao PDR should routinely include sanitation social and behavior change communication (SBCC), to address not only access to, but also use of, WASH facilities. 4D.8. Agriculture. Segments of the Lao PDR population continue to face persistent food insecurity, undernourishment, and limited access to nutritious foods, so support for greater food production remains important for nutrition. Interventions should focus on production; processing and storage; retail marketing; and purchase and consumption. These interventions clearly have the potential to increase household income, but to contribute to nutrition outcomes these interventiions should also go beyond increasing income, and promote consistent intake of diverse nutritious food. Interventions should also focus on food safety, and improved marketing and purchasing behaviors, as food systems are increasingly becoming important for Lao PDR. 4D.9. Education. Schools are an important platform for the delivery of comprehensive health and nutrition programs, given their ability to reach large numbers of students, families and communities. Interventions should include: education for healthy diets, school meals, school gardens, and provision of health and nutrition services, such as micronutrient supplementation and deworming. Interventions should reach preschool-age children (i.e., under 5 years of age) and should particularly focus on adolescent girls (secondary school girls). Education about food and nutrition is a key factor in children’s and adolescents’ healthy food choices and diets, including increased consumption of vegetables and fruits. 4D.10. Emergencies and Social Welfare. Emergencies and disasters, including climate change-related events such as droughts and floods, deepen food and nutritional vulnerability, particularly of the poor. Resulting food insecurity, where there is insufficient food production or inability to purchase sufficient nutritious food, drives chronic malnutrition. In addition, severe food insecurity and uncertainty in food consumption can lead to acute malnutrition, with a risk of wasting, illness, and even death. Core to the nutrition-related response in emergencies is the diagnosis and treatment of acute malnutrition and provision of supplementary feeding. These should be provided together with continuing access to nutritious foods, support for maternal and infant and young child feeding (IYCF) and WASH, and a broader approach to social protection for women and 28 children. For example, during emergencies, donations of powdered infant formula, or foods with low nutritional value, should be discouraged, in favor of nutritious foods. 4D.11. Creating an enabling environment. Nutrition-specific interventions, primarily delivered by the health sector and addressing the direct causes of malnutrition, should be combined with nutrition-sensitive interventions, delivered by other sectors, such as agriculture, education, and social welfare, addressing nutrition more indirectly. The enabling environment for multisectoral action on nutrition consists of governance and coordination; knowledge and evidence; resources and capacities – including individual, organizational, and systemic capacities. An important area for continued investment in capacity is monitoring, evaluation, accountability, and learning (MEAL), including a clear monitoring and evaluation framework, integrated monitoring, periodic evaluation, research, documentation and dissemination of good practices and lessons learned, and development of social accountability for nutrition investments and actions. V. Alignment with National Policies 5.1. This NPAN is guided by the VIIIth National Socio-Economic Development Plan 2016- 2020, the 9th NSEDP 2021-2025, and sectoral strategies such as the 8th Health Sector Development Plan 2016-2020, the 9th HSDP 2021-2025, the Health Sector Reform Strategy till 2025, the Agriculture Development Strategy (ADS) 2025 and Vision to 2030, and the Education and Sports Sector Development Plan 2016-2020. 5.2. This NPAN is also guided by the Law on Hygiene and Health Promotion (2019, revised from the previous Law on Hygiene, Disease Prevention, and Health Promotion 2012), the Policy on Primary Health Care (revised 2019), the Law on Food (2013), various national food laws and regulations, including the Regulation on Food Labelling (2020), the National Policy on Inclusive Education (2010), the Policy on Promoting School Lunch (2014), the National Social Protection Strategy 2030, and the Law on Disaster Management (2020). Central to this NPAN is the Prime Minister’s Decree 412 on Food Products and Feeding Equipment for Infants and Toddlers (2019), which protects and promotes breastfeeding by bringing the country in line with the International Code of Marketing of Breastmilk Substitutes (BMS). Importantly, this NPAN is consistent with and contributes to the National Strategy and Action Plan on Reproductive, Maternal, Newborn, and Child Health 2016-2025. National Socio-Economic Development Plan 5.3. The overall objective of the 8th National Socio-Economic Development Plan (NSEDP) comprises: political stability, poverty reduction, sustainable growth, effective management of natural resources, enhanced development, and participation in regional and international integration. Outcome 2 comprises: human capacity development, access to quality education and health services, cultural protection, and peace. Nutrition-related indicators under this Outcome include prevalence of underweight, stunting, and wasting in children under 5, and infant and under-5 mortality. 29 5.4. The overall objective of the 9th NSEDP comprises: graduation from Least Developed Country (LDC) status, addressing previous shortcomings and emerging challenges, and turning the nation’s endowments and potentials into a self-reliant and strong economy. Outcome 3 comprises: well-being, and food and income security. Nutrition-related indicators under this outcome include poverty reduction, production groups, maternal and infant mortality, gender equality, and children’s rights and development. Health Sector Development Plan 5.5. The summative evaluation of the 8th Health Sector Development Plan (HSDP) 2016- 2020, informed by mid-term review in 2018, observed that the highest priorities of the sector have been maternal and child health and nutrition. The health sector has 11 major indicators and targets; the first 2 of these indicators are nutrition-specific: i) underweight rate, ii) stunting rate iii) infant mortality rate, iv) under-5 mortality rate, v) maternal mortality ratio vi) percentage of births attended by skilled birth attendant, vii) immunization rate, viii) access to clean water, ix) access to latrine, x) health insurance coverage, and xi) percentage of model health villages. 5.6. The Lao health management information system comprises both surveillance and routine reporting through the District Health Information Software 2 (DHIS2) as well as special surveys, particularly the Lao Social Indicator Survey (LSIS). While progress has been made in underweight, stunting, and infant, child and maternal mortality, these all require continued attention in 2021-2025. The 9th HSDP 2021-2025 features continuation of plans across 8 major health programs: i) hygiene and health promotion, ii) communicable disease prevention and control, iii) treatment and rehabilitation, iv) protection of consumers of food, drugs, and health products, v) human resources for health sector, vi) health financing, vii) planning, information, and international cooperation, and viii) administration. 5.7. Within the hygiene and health promotion program, the plan includes nutrition interventions for: i) infant and young child feeding (IYCF), ii) consumption of safe and nutritious food, iii) nutrition management, iv) nutrition response in disasters and emergencies, v) research, surveillance, and health information. Health Sector Reform Strategy 5.8. The Health Sector Reform Strategy (updated to 2030) aims to introduce a sector- wide, systematic approach to affordable, reliable and accessible health services for all, with the vision to achieve Universal Health Coverage (UHC). Health sector reform priority areas are: i) human resources for health, ii) health financing, iii) governance, management and coordination, iv) service delivery, and v) health information system. 5.9. The Strategy uses largely the same major indicators and targets as the Health Sector Development Plan (HSDP), adding: life expectancy, malaria and TB mortality, HIV prevalence, and number of village health workers per village. In laying out the system reform areas (management and coordination, human resources, health financing, and health information system) the Strategy provides an overall background for the health system-related interventions essential for the nutrition strategy and action plan. 30 Lao PDR Nutrition Policy 5.10. Lao PDR prioritizes nutrition as a development issue. The first National Nutrition Policy was developed in 2008, followed by policies on Food Safety (2009), Food Security (2010), the first National Nutrition Strategy and Plan of Action (NNSPA) 2011-2015, the Law on Hygiene, Disease Prevention and Health Promotion (2012), the Law on Hygiene and Health Promotion (2019), and the second (and current) National Nutrition Strategy to 2025 and Plan of Action 2016-2020. Nutrition is named as a component of the Primary Health Care Policy (2019). The NNSPA provides the overarching framework for nutrition programming in Lao PDR for government, donors, non-governmental and civil society organizations. A recent nutrition policy landscape analysis found that the health sector makes the most nutrition-specific reference in sectoral policies and strategies, with the education, agriculture, and water, sanitation and hygiene (WASH) sectors making fewer references to nutrition-sensitive interventions (NIER NIPN 2019)11. Bottlenecks to effective policy implementation were found in: i) leadership and management, ii) nutrition workforce, iii) nutrition financing, iv) nutrition monitoring, and v) nutrition governance. 5.11. Recommendations were to: i) improve multisectoral coordination, especially at subnational level, ii) increase public financing of nutrition, iii) enhance human resources for nutrition, iv) ensure availability and use of data for decision-making, and v) increase access and coverage of nutrition interventions. These recommendations are particularly relevant for Outcome 3 of Component 3 in this NPAN, the system-related interventions essential for the nutrition action plan, including the portions of the plan on management, coordination, monitoring and evaluation. VI. Alignment with Global and Regional Guidance 6.1. This NPAN is guided by the Sustainable Development Goals (SDGs), global normative guidance on nutrition, and nutrition-related policies of the Association of Southeast Asian Nations (ASEAN). In turn this NPAN forms part of Lao PDR’s contributions to the SDGs, global goals, and ASEAN-wide initiatives. Nutrition and the Sustainable Development Goals 6.2. Sustainable Development Goal 2 directly addresses nutrition, aiming to “end hunger, achieve food security and improve nutrition, and promote sustainable agriculture.” Global efforts to combat hunger and malnutrition have advanced significantly since 2000. However, ending hunger, food insecurity and malnutrition for all people requires continued and focused efforts. With an anticipated global economic downturn associated with COVID-19, stunting and wasting among children are likely to rise, and food insecurity is likely to continue to worsen. Focusing on nutrition will be more important than ever before. 6.3. Sustainable Development Goals 1 through 6 are all related to nutrition – SDG 1. poverty; 2. hunger; 3. health; 4. education; 5. gender equality; 6. water and sanitation. Indeed, most of the SDGs have nutrition-relevant indicators, and all the SDGs have some link 31 to nutrition. In this way, improving nutrition goes beyond SDG 2 alone; it contributes to improving health and working to end poverty, and is essential to making progress across all of the SDGs. 6.4. Malnutrition is often an invisible impediment to the achievement of many SDGs. This results not just from insufficient food, but also from multiple interrelated factors linking health, education, water, sanitation, hygiene, access to food and resources, gender equality and women’s empowerment, and more. Nutrition is therefore both a maker and a marker of development, and is central to the global development agenda embodied in the SDGs. Global Guidance on Nutrition 6.5. According to the recent State of the World’s Children Report 2019, “Children, food and nutrition” (UNICEF 2019) malnutrition continues to undermine the capacity of children to grow and develop to their full potential, and threatens the development of economies and nations. Malnutrition is driven by poor quality of diets. Improving children’s nutrition requires food systems to deliver nutritious, safe, affordable and sustainable diets. 6.6. Another key report has been the State of Food Security and Nutrition 2020, “Transforming food systems for affordable healthy diets” (FAO 2020). According to this report, the world is not on track to achieve Zero Hunger by 2030, as rates of stunting, wasting, low birth weight, and child overweight remain high, and nutritional status is likely to deteriorate due to COVID-19. Food insecurity worsens diet quality and increases malnutrition. While countries face challenges in accessing food, there are also challenges in terms of healthy diets, which are unaffordable for the poor. To increase the affordability of healthy diets, the cost of nutritious food must come down throughout the food supply chain. This requires transforming food systems, rebalancing agricultural policies towards nutrition-sensitive investment, improving social protection, and promoting behavior change for nutrition. 6.7. Related to the above report is the Asia-Pacific Regional Overview of Food Security and Nutrition 2020, “Maternal and child diets at the heart of improving nutrition” (FAO 2021). According to this Asia-Pacific regional report, endorsed by UNICEF, WFP, and WHO, regional progress on nutrition has slowed, and in the time of COVID-19, it is important to build resilience to respond to future disasters and emergencies. Countries should focus on improving maternal and child diets, increasing affordability (reducing cost) of nutritious diets, and using data to measure progress and to document evidence. All systems – the food system, WASH, health, social protection, and education – have roles to play in supporting healthy maternal and child diets and improving nutrition. 6.8. The Global Nutrition Report 2020, “Action on Equity to End Malnutrition,” focuses on nutrition equity. Unequal systems and processes create opportunities and barriers to healthy diets, and ultimately driving unfavorable nutrition outcomes. The report’s key recommendation is to mainstream nutrition into food and health systems, supported by strong financing and accountability, in order to focus action where the need is greatest to achieve maximum impact. 32 ASEAN Commitments on Nutrition 6.9. The Association of Southeast Asian Nations (ASEAN) adopted a Leaders’ Declaration on Ending All Forms of Malnutrition in November 2017. The Declaration expresses the highest level of political commitment for urgent acceleration of evidence-based multisectoral actions to reduce and ultimately end all forms of malnutrition. 6.10. ASEAN has drafted a Strategic Framework and Plan of Action on Nutrition 2018- 2030, which operationalizes the Leaders’ Declaration. The plan collates commitments made in the context of the Leaders’ Declaration by senior officials’ meetings on health, social welfare, education, and agriculture and forestry. Examples of key expected ASEAN-wide region-specific outputs include: nutrition package guidelines for maternal nutrition, breastfeeding, and school nutrition; standards for the implementation of integrated management of acute malnutrition (IMAM); research on nutrition-vulnerable and marginalized groups; and development of a multisectoral approach model. VII. Conceptual Framework: Causes, Problem, and Consequences 7.1. Given the above assessment of global evidence and lessons learned from nutrition programs in Lao PDR in recent years, this NPAN 2021-2025 updates the conceptual framework and strategic framework from the National Nutrition Strategy to 2025. The conceptual framework lays out the immediate (direct), underlying (indirect), and basic causes of malnutrition in Lao PDR. In the previous version (NNS to 2025), the basic causes are divided into: institutional and resource-based, and social and economic. 7.2. This updated version (NPAN 2021-2025) uses the same structure of direct (immediate), indirect (underlying), and basic causes, but aims to be clearer and more comprehensive. The basic causes are unified into one set, and expanded to include: gender inequality, and vulnerability to disasters, emergencies, and climate change risk. The basic, indirect, and direct causes extend further into a statement of the problem: maternal, child and adolescent malnutrition. In turn, the problem extends further into consequences: mortality, poor physical and cognitive development, decreased social and economic growth, and risk of intergenerational perpetuation. 7.3. These consequences provide the rationale for the importance of investment in nutrition, and the direct link to the National Socio-Economic Development Plan (NSEDP) and the broader national and global development field. The problem (child, adolescent, and maternal malnutrition) is manifested and indicated by a range of key indicators – stunting, wasting, underweight, low birth weight, overweight, and anemia – all of which serve as the key indicators for the overall goal of this strategy and plan of action. In a similar way, all of the basic, indirect, and direct causes of malnutrition are associated directly with strategic objectives in the strategic framework, with associated indicators. 33 7.4 During consultations for this NPAN, some stakeholders suggested a much greater simplification of the conceptual framework, in order to develop a strategy with even fewer, clearer strategic objectives. However, other stakeholders emphasized the need to have a link to the conceptual framework of the previous NPAN 2016-2020, as the current National Nutrition Strategy has already been approved to 2025. The following pages show the conceptual framework of the previous NPAN 2016-2020, and how this has evolved to the updated version, NPAN 2021-2025. Figure 5 shows the conceptual framework for NPAN 2016-2020, while Figure 6 shows the conceptual framework for this NPAN 2021-2025. As discussed above, for this NPAN 2021-2025, the basic causes are simplified, and there is a clear statement of the problem and its consequences. Figure 5: Conceptual Framework for NPAN 2016-2020 34 Figure 6: Conceptual Framework for NPAN 2021-2025 35 Conceptual Framework: Causes of Malnutrition A. Direct (Immediate) Causes 1. Inadequate nutrient intake. 2. Poor access to and use of water and sanitation, poor hygiene, and diseases. B. Indirect (Underlying) Causes 3. Lack of availability of and access to nutritious food. 4. Poor knowledge and behavior about nutritious food. 5. Poor access to health and nutrition services. C. Basic Causes 6. Limitations in governance, management and coordination. 7. Insufficient trained human resources. 8. Inadequate health and nutrition services. 9. Inadequate information system. 10. Inadequate financial system. 11. Vulnerability to disasters and emergencies. 12. Some social norms and behaviors hinder nutrition. 13. Gender inequality. VIII. Updated Vision, Mission, and Overall Goal of National Nutrition Strategy and Plan of Action, and Indicators for Overall Goal Vision: A prosperous country, with a healthy, food-secure population, with reduced malnutrition and poverty. Mission: Create an enabling environment to reduce all forms of malnutrition in Lao PDR, focus on nutrition priorities, and ensure effective multisectoral coordination, implementation, and monitoring and evaluation at all levels. Overall Goal: To reduce malnutrition among women and children and improve the nutritional status of all Lao people so that they are healthy and have a high quality of life, and thus contribute to the achievement of national socio-economic development targets by 2025. Indicators for Overall Goal 8.1. The below Indicators for the Overall Goal are a mix of UNICEF/WHO-recommended global indicators, indicators already collected by the Lao Social Indicator Surveys (LSIS) every 5 years, and indicators that have been collected in the past by the Lao nutrition program. They are important to track at national level – stunting, wasting, and underweight in children under 5 years of age, low birth weight, and anemia in children under 5 and in women of reproductive age (15-49 years of age). One of the Indicators for the Overall Goal is overweight in children 36 under 5 years of age; while this is still low, as Lao PDR develops, and food systems and diets change, it is important to keep tracking over-nutrition as it has important negative health consequences, such as increased non-communicable diseases (NCDs), and negative social effects. The previous NPAN 2016-2020 included an indicator for iodine, but LSIS1 already showed a favorable level of iodine in children, and LSIS2 showed very high household consumption of iodized salt. Given the good level of iodine in children and the expense of monitoring iodine levels in urine, this is no longer an indicator for the Overall Goal. However, food fortification, including salt iodization, remains an important activity in this NPAN. The percentage of infants under 6 months of age who are exclusively breastfed is a key nutrition outcome indicator that is included both as an Indicator for the Overall Goal, as well as an outcome indicator for the related Strategic Objective and Intervention, further below. Table 1: Expect to target 11 indicators approved by the National Assembly 2021-2025 & 2030 No. Indicators 2019 2020 2021 2022 2023 2024 2025 2030 1 Prevalence of wasting (low weight- for-height) 20.5 20 19 18 17 16 15 10 2 Prevalence of stunting (low height- for-age) 32.5 32 31 30 29 28 27 23 3 Infant mortality > 1 year /1000 / new born alive 34 30 28 26 24 22 20 <12 4 Infant mortality > 5 ປີ /1000 / new born alive 42 40 38 36 34 32 30 <25 5 Maternal mortality / 100.000 / new born alive 167 160 150 140 130 120 110 <70 6 Born with the help of a doctor 75 80 81 81 82 83 84 >90 7 Use of vaccines 90 95 95 95 95 95 95 100 8 Clean water consumption 85 90 91 92 93 94 95 >95 9 Using the toilet 75 80 81 82 83 84 85 >90 10 Health insurance coverage 80 94 94 94.5 95 95.5 96 >96 37 11 Health model village 78 80 81 82 83 84 85 >85 Table 2: Indicators for Overall Goal Indicator 2012 data (%) LSIS 1 2015 data (%) 2017 data (%) MTR / LSIS 2 2020 target (%) 2025 target (%) 1. Prevalence of stunting (low height- for-age) in children under 5 years of age 44 42 33 32 (HSDP 2021-25) 27 (DPC, MOH) 2. Prevalence of wasting (low weight- for-height) in children under 5 years of age 6 6 9 < 5 < 5 3. Prevalence of underweight (low weight-for-age) in children under 5 years of age 27 22 21 20 (HSDP 2021-25) 15 (DPC, MOH) 4. Prevalence of children aged 6-59 months with anemia (Hb <11g/dL) 41 40 44 30 30 5. Prevalence of women of reproductive age (WRA) (15-49 years of age) with anemia (Hb <12g/dl) 36 30 40 23 15 6. Percentage of infants born with low birth weight (<2,500 g) 15 6.5 11 8 7. Prevalence of overweight (high weight-for-height) in children under 5 years of age 2 2 3.5 ≤ 2 ≤ 2 8. Percentage of infants under 6 months of age who are exclusively breastfed 40 40 45 50 60 38 Sources of indicators, data, and targets: NPAN 2016-2020, LSIS 2017, UNICEF/WHO Global Nutrition Monitoring Framework, except where marked HSDP, Health Sector Development Plan 8.2. Nutrition disparities. All of the Indicators for the Overall Goal are important to track at national level. At the same time, Section 4A above shows that there are significant disparities across Lao PDR, with greater malnutrition, in general, found in remote, rural, ethnic minority communities who find challenges in accessing nutrition, health, and social services. One of the Guiding Principles of this NPAN (see Section 14 below) is a focus on the most vulnerable groups. It is therefore important that, where possible, these Indicators for the Overall Goal are monitored at provincial and district level to guide program implementation. Nutrition actions should focus on priority provinces with highest rates of malnutrition. However, even a province with good overall nutrition status may include districts with poor nutrition, so nutrition actions should focus on those districts. Even within districts, there may be sub-districts or villages with poor nutrition, and so further specific targeting may be appropriate. 8.3 Nutrition contributions to national health indicators. As discussed above, nutrition efforts are aligned with national policies, and nutrition programs provide contributions to the achievement of targets at the levels of national development, the overall health sector, and maternal and child health (MCH). All 8 Indicators for the Overall Goal above contribute to MCH outcomes. The Ministry of Health (MOH) reports annually to the National Assembly on 11 national-level health indicators. Of these, this NPAN contributes indirectly to 3 broad indicators and targets: infant mortality rate (IMR) per 1000 live births, under-5 mortality rate (U5MR) per 1000 live births, and maternal mortality ratio per 100,000 live births. This NPAN contributes directly to 4 indicators and targets: two are NPAN Indicators for the Overall Goal -- underweight and stunting, while two others are NPAN WASH outcome-level Indicators – use of clean water and use of latrine. Table 3: National health indicators and annual targets to which nutrition programs contribute indirectly Data Annual targets National health indicator 2012 (LSIS 1) 2015 2017 (LSIS 2) 2020 2021 2022 2023 2024 2025 Infant mortality rate (IMR) / 1000 68 51 (UN) 40 30 28 25 22.5 21 20 Under-5 mortality rate (U5MR) / 1000 79 67 (UN) 46 40 37 35 33 32 30 Maternal mortality ratio (MMR) / 100,000 220 206 (Census) 197 (UN 2015) 160 150 135 120 115 100 39 Source for targets: Health Sector Development Plan (HSDP) 2021-2025 Table 4: National health indicators and annual targets to which nutrition programs contribue directly and which are included in this NPAN Annual targets National health indicator Where in this NPAN 2017 data (LSIS 2) 2020 2021 2022 2023 2024 2025 Underweight (%) Indicator for Overall Goal 21.1 20 19 18 17 16 15 Stunting (%) Indicator for Overall Goal 33 32 31 30 29 28 27 Use of clean water (%) Outcome Indicator 7 (households), Indicator 10 (schools) 83.9 90 91 92 93 94 95 Use of latrine (%) Outcome Indicator 8 (households), Indicator 11 (schools) 73.8 80 81 82 83 84 85 ` Source for targets: Department of Planning and Cooperation (DPC), Ministry of Health, 2021 Note: there are slight differences in the underweight and stunting targets between Table 1, which are long-term targets and are taken from HSDP 2021-2025, and Table 3, which are targets set and reported on annually. Strategic Framework for NPAN 2021-2025 Components: Component 1: Address direct (immediate) causes of malnutrition. Component 2: Address indirect (underlying) causes of malnutrition. Component 3: Address basic causes of malnutrition, create an enabling environment, and promote multisectoral action. Strategic Objectives: SO1: Improve nutrient intake. SO2: Improve water and sanitation, promote hygiene, prevent and control diseases. 40 SO3: Increase availability of and access to nutritious food. SO4: Improve child and adolescent knowledge and behaviors about nutritious diets. SO5: Improve mother and child health and care. SO6: Strengthen institutional capacity, governance, management, and coordination. SO7: Strengthen human resources. SO8: Improve healthhealth service delivery system for communities. SO9: Improve information management and use of evidence for decision-making. SO10: Improve financial management and increase investment. SO11: Ensure effective preparedness and response to disasters and emergencies, and social protection. SO12: Scale up social and behavior change communication (SBCC) for nutrition. SO13: Promote gender equity. IX. Guiding Principles for NPAN National Nutrition Strategy and NPAN 2016-2020 The National Nutrition Strategy to 2025 and Plan of Action 2016-2020 (NNSPA) articulated five key guiding principles for nutrition action in Lao PDR. These were to: 1. Define a realistic strategy 2. Support effective management 3. Achieve measurable outcomes 4. Ensure efficient and effective implementation 5. Address gender Additional Principles 2021-2025 Consultations for this National Plan on Action on Nutrition (NPAN) 2021-2025 generated ten additional guiding principles. Many of these echo and extend the existing five above, while others, based on stakeholders’ experience of implementing nutrition activities to date, are newly-articulated: 6. Be based on evidence: This NPAN is based on a review of global and national evidence and national and sub-national consultation recommendations. 7. Be feasible: Echoing principle 1 above, this NPAN aims to be realistic, working within existing resources and capacities. 8. Harmonize with national policies and planning frameworks: Providing more detail to principle 2 above, this NPAN aims to be explicitly aligned with national policies and frameworks. 41 9. Emphasize multisectoral integrated planning: Extending principle 2 above, this NPAN incorporates plans and interventions from multiple sectors (health, education, and agriculture). 10. Promote multisectoral coordination: Further extending principle 2 and directly related to principle 9, this NPAN aims to foster greater coordination to address nutrition. 11. Increase accountability and transparency: This principle extends principle 3 above. The process of NPAN development has featured wide stakeholder involvement. The main accountability method is the updated monitoring and evaluation framework (Section 13 below). In addition, this NPAN fosters multisectoral information sharing and appropriate use of evidence. 12. Feature participatory methods: As mentioned in principle 11 above, NPAN development has involved a wide range of stakeholders in the planning process. 13. Be based on human rights principles: This NPAN is underpinned by the recognition of the human right to adequate food. 14. Focus on the most vulnerable groups: This NPAN recognizes the importance of equity, focusing on priority geographical locations (provinces, districts) and priroirty populations (pregnant women and children) who are most vulnerable to malnutrition and its effects. 15. Promote gender equality: Extending principle 5 above, this NPAN goes further than before in recognizing the importance of gender in nutrition efforts, and actively promotes gender equity for improved nutrition. X. Strategic Framework A. Components and Strategic Objectives 3 Components and 13 Strategic Objectives: Component 1: Address direct (immediate) causes of malnutrition. SO1: Improve nutrient intake. (Health) SO2: Improve water and sanitation, promote hygiene, prevent and control diseases. (Health/WASH) Component 2: Address indirect (underlying) causes of malnutrition. SO3: Increase availability of and access to nutritious food. (Agriculture) SO4: Improve child and adolescent knowledge and behaviors about nutritious diets. (Education) SO5: Improve mother and child health and care. (Health) Component 3: Address basic causes of malnutrition, create an enabling environment, and promote multisectoral action. SO6: Strengthen institutional capacity, governance, management, and coordination. (Multisectoral) 42 SO7: Strengthen human resources. (Multisectoral) SO8: Improve health service delivery system for communities. (Health) SO9: Improve information management and use of evidence for decision-making. (Multisectoral, including Ministry of Planning and Investment) SO10: Improve financial management and increase investment. (Multisectoral, including Ministry of Finance) SO11: Ensure effective preparedness and response to disasters and emergencies, and social protection. (Multisectoral, including Ministry of Labor and Social Welfare) SO12: Scale up social and behavior change communication (SBCC) for nutrition. (Multisectoral) SO13: Promote gender equity. (Multisectoral, including Lao Women’s Union) Component 1: Address direct (immediate) causes of malnutrition. This Component includes Strategic Objectives (SOs) that directly improve nutrition and reduce malnutrition at the individual and household level. These nutrition-specific SOs are to improve nutrient intake, with a primary focus on the first 1000 days (during pregnancy up to 2 years of age), to promote hygiene, and to prevent and control diseases. The health sector leads this Component, with education, agriculture, and other sectors playing important supportive roles. SO1: Improve nutrient intake. (Health) This SO focuses on maternal, infant, and young child nutrition (MIYCN) in the first 1000 days (during pregnancy up to 2 years of age). This SO emphasizes early breastfeeding within an hour of birth and exclusive breastfeeding for the first 6 months, followed by supplementary feeding from 6 months to 2 years and later. This SO also emphasizes consumption of safe, adequate, varied, and healthy diets for children under 5 years of age; during the first 8000 days (up to 21 years of age); for pregnant, postpartum, and breastfeeding women; and throughout the course of life. In addition to dietary counseling and promotion of nutritious and healthy food, this SO also includes promotion of healthy diets and provision of micronutrient supplementation, including Vitamin A and iron-folic acid, and food fortification. This SO requires availability of and access to sufficient, safe, nutritious and healthy food (SO3), and support for health and nutrition care (SO5). This SO is directly related to social and behavior change communication (SO12) and promotion of gender equity (SO13), and is important during disasters and emergencies (SO11). SO2: Improve water and sanitation, promote hygiene, prevent and control diseases. (Health/WASH) This SO covers environmental health and hygiene; focuses on construction, renovation, provision, access to and maintenance of systems for clean water sources for drinking, handwashing stations, and latrines, for use in the home, community, health facilities, and schools; and emphasizes hygiene and sanitation behaviors and practices to prevent and control diseases, and includes provision of deworming in the community. This SO promotes environmental and health impact assesements (EIAs/HIAs) and required adjustments to cope with disasters and emergencies, including climate change-related events, such as sustainable infrastructure for flood, and is related to SO11. With increased access to sanitation and use of latrines, this SO aims to reduce, and ultimately eliminate, open defecation. This SO re-works 43 SO2 from NPAN 2016-2020 and aims to address both communicable and non-communicable diseases (NCDs). Social and behavior change communication (SO 12) is particularly important for this SO. While the health sector, leads this SO, both education and agriculture sectors have important supportive roles. Education about WASH in schools supports hygiene behaviors at home. Agricultural extension services should encourage separating animals from households to reduce human exposure to animal feces. Component 2: Address indirect (underlying) causes of malnutrition. This Component includes Strategic Objectives that enable the promotion of health and nutrition and the reduction of malnutrition. These nutrition-sensitive SOs include availability of and access to food; mother and child health and care; and child and adolescent knowledge and behaviors. This Component includes improving food security, food safety, and the food system. In this Component, the SOs are about well-functioning sectoral systems for nutrition. Each SO has one lead sector (health, agriculture, education). In addition, each SO should also address all of the multisectoral and cross-cutting objectives (SOs 6-13) below. SO3: Increase availability of and access to nutritious food. (Agriculture) This SO focuses on increasing production of safe, nutrient-rich crops, vegetables, fruit, small livestock, fish, frogs, and other protein sources, for diet diversification and consumption in the home. This SO includes maximizing opportunities to add nutritional value at every step of the agriculture value chain, such as planning, production, post-harvest processing, preservation, storage, marketing, and distribution. This SO includes improving community participation in natural resource and small infrastructure management. This SO is Includes improving food safety and the food system for nutrition, including food labelling, and addressing land use systems to promote nutrition. This SO includes attention to gender dynamics of agricultural production, ensuring balance between women’s empowerment, women’s involvement in production, and women’s roles for child raising, and is related to gender equity, SO13. SO4: Improve child and adolescent knowledge and behaviors about nutritious diets. (Education) This SO focuses on increasing knowledge and awareness about nutrition, for students, parents, communities, and teachers. Within this SO are emphases on early childhood education, and education about nutrition for adolescent girls (secondary school girls). Promotion of nutrition knowledge and behaviors is primarily through the curriculum, and also includes education through activities such as school gardens. This SO includes provision of micronutrient supplementation in schools, particularly iron-folic acid for secondary school girls and deworming for primary school children. The health sector leads micronutrient supplementation and deworming, cooperating with the education sector, in order for schools to serve as delivery locations for these interventions. This SO also includes promotion of access to clean water, use of latrines, and handwashing in schools. Included in this SO is the integration of nutrition into broad school-based health activities such as maternal and child health, immunization, education about sexual and reproductive health, and other health promotion activities. This SO includes provision of school lunches within broader efforts to improve children’s access to education, social inclusion, social protection, and community mobilization. Promotion of nutrition knowledge and behaviors is also meant to address the emerging burden of 44 overweight, obesity, and non-communicable diseases (NCDs). This SO emphasizes the importance of nutrition during the first 8000 days (up to 21 years of age) and throughout the course of life, and this SO requires the involvement of school teachers, parents of school children, and communities. This SO is related to social and behavioral change communication (SBCC), SO12. SO5: Improve mother and child health and care. (Health) This SO focuses on provision of nutrition knowledge and counseling, and nutrition-related care, for antenatal women, parents, infants, and children under 5 of age, at health care facilities, and during outreach in the home and community. This SO includes provision of integrated management of newborn and childhood illnesses (IMNCI), including integrated management of acute malnutrition (IMAM). This SO emphasizes integrated delivery of nutrition services within reproductive, maternal, newborn, child, and adolescent health (RMNCAH) and primary health care (PHC) services. The Education sector has an important complementary role to play in this SO. Component 3: Address basic causes of malnutrition, create an enabling environment, and promote multisectoral action. This Component includes Strategic Objectives that address the basic causes of malnutrition, including poverty; insufficient institutional capacity and coordination; inadequate human resources; inadequate information, monitoring and evaluation systems; and insufficient effectiveness of aid and public investment. In this Component, the SOs are about well- functioning institutions which create an enabling environment, including law, policy, strategy, good governance, and effective management. In addition, this NPAN includes a greater emphasis on cross-cutting issues, such as nutrition in disasters and emergencies, including those brought about by climate change, social and behavior change communication (SBCC), and gender equality. These SOs require coordinated multisectoral approaches. SO6: Strengthen institutional capacity, governance, and coordination. (Multisectoral) This SO focuses on governance, management, and planning of nutrition policies, programs, and interventions. Important to this SO are promoting the integration of nutrition into the regular across sectors and across central, sub-national, and community levels. This coordination should lead to convergence of nutrition actions in the highest-priority locations and populations, with coordinated technical approaches, maximizing impact, and minimizing duplication and fragmentation. This SO includes linkages with global and regional efforts related to nutrition, such as the Sustainable Development Goals and ASEAN efforts to eliminate all forms of malnutrition. This SO also includes promoting the involvement of public and private sectors, NGOs, and businesses. Within this SO, there is a focus on improving the quality of multisectoral collaboration at all levels, i.e., using existing coordination mechanisms to maximize effectiveness. This SO is directly related to SO 7 to SO 10 below. SO7: Strengthen human resources. (Multisectoral) This SO focuses on improving the capacities of staff and volunteers across all sectors and at all levels to enable effective management and delivery of nutrition interventions. This SO includes: 45 addressing the shortage of staff (addressing quantity); providing management, planning, monitoring, evaluation, and supportive supervision for staff (improving quality); providing integrated capacity building, both pre-service and in-service; and promoting coordination and joint action across sectors in investing in human resource development for nutrition. SO8: Improvehealth service delivery system for communities. (Health) This SO focuses on improving integrated delivery of multisectoral, health, and nutrition services at both fixed facilities and during outreach in the community. Within the health sector, this is the primary health care (PHC) approach, providing integrated quality accessible and equitable services at the community level. This SO includes building the health service network towards Universal Health Coverage (UHC), ensuring that communities, especially the most vulnerable, have access to services, leaving no one behind. This SO includes improving the referral system for severe malnutrition as well as promoting the involvement of private sector. Central to this SO is the development and expansion of the health model village program and the nutrition model village program. For this SO, the health sector serves as the lead responsible for implementation and monitoring, with other sectors playing important supporting roles. SO9: Improve information management and use of information for decision-making. (Multisectoral, including Ministry of Planning and Investment) This SO focuses on strengthening nutrition information management and use. This includes strengthening monitoring and evaluation (M&E), surveillance, research, data collection, analysis, and reporting, for use in the improvement of policies, programs, and projects. This SO includes the use of a variety of appropriate, innovative technologies, including digital technology. This SO includes building capacity for M&E at each level, improving existing nutrition information systems in different sectors (for example, DHIS2 in the health sector and EMIS in the education sector), working towards interoperability, developing needed tools, and sharing nutrition information, experience, and good practices across sectors. This SO includes the involvement of the Ministry of Planning and Investment, and making full use of nutrition knowledge management projects, such as the National Information Platform for Nutrition (NPIN). SO10: Improve financial management and increase investment. (Multisectoral, including Ministry of Finance) This SO focuses on strengthening financial management, planning, tracking, and reporting at all levels. This SO also focuses on steps to increase domestic public and private investment, building towards financial sustainability. This SO aims to increase the effectiveness of both official development assistance (ODA) and public finance, and to engage with the private sector on possibilities for financing nutrition. This SO includes the development of policy and appropriate guidelines for effective use of funds, and efforts to strengthen the capacity of staff in financial management. This SO includes advocacy for a favorable financial environment for investment in nutrition. This SO includes the involvement of the Ministry of Finance and relevant financial institutions. In this SO, lessons should be learned from the European Union’s nutrition budget support program, and applied broadly. 46 SO11: Ensure effective preparedness and response to disasters and emergencies, and social protection. (Multisectoral, including Ministry of Labor and Social Welfare) This SO focuses on ensuring the delivery of nutrition interventions before, during, and after disasters and emergencies, including climate change-related events such as droughts and floods, and epidemics such as COVID-19. This SO aims to increase sustainable infrastructure for nutrition. It includes the development of technical support and guidelines for nutrition in disaster and emergency preparedness and response, and strengthening national and sub- national capacity to manage nutritional needs in times of emergencies and disasters. This SO includes use of mid-upper-arm circumference (MUAC) measurement for nutrition surveillance in emergencies. This SO includes involvement of the Ministry of Labor and Social Welfare and other relevant agencies. This SO includes use of all available evidence on the impact of COVID- 19 on nutrition in Lao PDR, such as studies conducted by the National Information Platform for Nutrition (NIPN) and others. SO12: Scale up social and behavior change communication (SBCC) for nutrition. (Multisectoral) SBCC is essential for creating an enabling environment for change. SBCC is an integral component of every nutrition intervention in every sector. All sectors above – health, agriculture, education, and WASH – are expected to continue to invest in and implement activities based on the Lao PDR Nutrition SBCC Strategy and Guidelines. Effective SBCC requires more than information, and includes access to services, education and counseling for motivation and support for change, and a shift in social norms. In addition, sectors should coordinate and integrate SBCC approaches across sectors. SO13: Promote gender equity. (Multisectoral, including Lao Women’s Union) Good nutrition and gender equality are directly related and mutually reinforcing. For example, poor sexual and reproductive health lead to poor maternal and child nutrition. Girls having worse access to educational opportunities than boys leads to poor life choices available for young women. Women having less decision-making than men about food production and household consumption leads to worse nutrition outcomes for women and children, while investments in farm small infrastructure may reduce women’s labor. Women’s participation in agricultural production is important, but increasing this should not be at the cost of reducing women’s ability to provide care for their infants and children, and a balance should be sought that increases women’s opportunities. This SO focuses on interventions across sectors for women’s empowerment, increasing women’s income and influence, and realizing women’s and children’s rights. Included in this SO are activities to increase awareness about the importance of gender in nutrition, and to strengthen capacity and to provide technical support for promoting gender equity, within each sector and at all levels. This SO includes involvement of the Lao Women’s Union. 47 B. Interventions and Indicators by Strategic Objective Table 5: Interventions and Indicators by Strategic Objective This table lists the 3 Components and 13 Strategic Objectives (SO). Alongside each SO are set a set of Interventions and Indicators. The Interventions were decided through the consultative process for this NPAN, with the main sectors (health, agriculture, and education) taking responsibility for defining their own Interventions and ensuring that these are consistent with sectoral strategies and plans. The Indicators are a mix from NPAN 2016-2020, LSIS 2017, and UNICEF/WHO Global Nutrition Monitoring Framework; they were finalized after the M&E Consultation held for this NPAN during April 2021. Component 1: Address direct (immediate) causes of malnutrition. 1. Inadequate nutrient intake. 2. Poor access to and use of water and sanitation, poor hygiene, and diseases Strategic Objectives (Sector primarily responsible for SO) Interventions (Measures) (Sector primarily responsible for implementation) Indicators (Sector responsible for reporting) SO1: Improve nutrient intake. (Health) 1. Promote women’s, maternal, infant, and young child nutrition. (Health) Indicator 1: Percentage of pregnant women receiving counseling for breastfeeding, food supplementation and child growth monitoring. (Health) Indicator 2: Percentage of newborns initiated on breastmilk within 1 hour after delivery. (Health) Indicator 3: Percentage of Infants under 6 months of age who are exclusively breastfed. (Health) 2. Provide micronutrients for target women and children. (Health) Indicator 4: Percentage of pregnant women who receive at least 90 iron-folic acid (IFA) tablets. (Health) Indicator 5: Percentage of women 12-25 years of age taking iron-folic acid (IFA) tablets every week. (Health) Indicator 6: Percentage of children 6-59 months of age taking vitamin A supplementation in the past 6 48 months. (Health) SO2: Improve water and sanitation, promote hygiene, prevent and control diseases. (Health/WASH) 3. Improve and integrate hygiene, clean water, and sanitation systems; increase access and promote hygiene behaviors and practices. (Health/WASH) Indicator 7: Percentage of households using improved source of (clean and safe) drinking water. (Health/WASH) Indicator 8: Percentage of households using improved sanitation facility (latrine). (Health/WASH) Indicator 9: Percentage of households using handwashing facility with soap. (Health/WASH) Indicator 10: Percentage of kindergarten and primary schools using improved source of (clean and safe) drinking water. (Education/WASH) (Please note this Indicator is also listed under SO4 Education below) Indicator 11: Percentage of kindergarten and primary schools using improved sanitation facility (latrine). (Education/WASH) (Please note this Indicator is also listed under SO4 Education below) Indicator 12: Percentage of kindergarten and primary schools using handwashing facility with soap. (Education/WASH) (Please note this Indicator is also listed under SO4 Education below) 4. Prevent and control childhood diseases and provide deworming for children under 5 years of age. (Health) Indicator 13: Percentage of children 12-59 months of age taking deworming. (Gender-disaggregate, girls-boys) (Health) Indicator 14: Percentage of children under 5 years of age with diarrhea for whom treatment was 49 sought at a health facility. (Gender-disaggregate, girls-boys) (Health) Indicator 15: Percentage of children under 2 years of age who have been fully immunized. (Gender- disaggregate, girls-boys) (Health) Component 2: Address indirect (underlying) causes of malnutrition. 3. Lack of availability of and access to nutritious food. 4. Poor knowledge and behavior about nutritious food. 5. Poor access to health and nutrition services. SO3: Increase availability of and access to sufficient, safe, and nutritious food. (Agriculture) 5. Promote production of diverse nutritious crops, vegetables, and fruits through clean agriculture. (Agriculture) 6. Promote production of protein- and calcium-based foods from small animal-raising and fisheries. (Livestock and Fisheries) 7. Promote community participation in planning, management, and sustainable use of natural resources and non-timber forest products (NTFPs). (Forestry) 8. Promote the agriculture value chain system for nutrition. (Technical Extension and Agriculture Processing) Indicator 16: Number of families producing diverse crops, vegetables, and fruits through clean agriculture for consumption. (Agriculture) Indicator 17: Number of families raising small animals, fish, aquatic animals, and insects, or taking from natural sources, for consumption. (Livestock and Fisheries) Indicator 18: Number of target villages which sustainably manage, use, and report on natural resources and non-timber forest products (NTFPs). (Forestry) Indicator 19: Number of production groups able to implement regular activities, such as food preservation, processing, marketing, and value improvement. (Technical Extension and Agriculture Processing) 50 SO4: Improve child and adolescent knowledge and behaviors about nutritious diets. (Education) 9. Promote nutritious and healthy diets through integration into the school curriculum, including small agricultural activities in schools, and other activities. (Education) 10. Support the provision of micronutrient supplementation, deworming, immunization, and other health interventions in schools. (Joint Education and Health) 11. Promote hygiene, including clean water, sanitation, and handwashing in schools. (Education/WASH) 12. Provide and promote nutritious school lunches. (Education) Indicator 20: Percentage of schools using nutrition education curriculum and related activities. (Education) Indicator 21: Percentage of secondary school girls taking iron-folic acid (IFA). (Joint Education and Health) Indicator 22: Percentage of primary school children receiving deworming. (Gender-disaggregate, girls- boys) (Joint Education and Health) Indicator 10: Percentage of kindergarten and primary schools using improved source of (clean and safe) drinking water. (Education/WASH) (Please note this Indicator is also listed under Health above) Indicator 11: Percentage of kindergarten and primary schools using improved sanitation facility (latrine). (Education/WASH) (Please note this Indicator is also listed under Health above) Indicator 12: Percentage of kindergarten and primary schools using handwashing facility with soap. (Education/WASH) (Please note this Indicator is also listed under Health above) Indicator 23: Percentage of target schools providing and promoting nutritious school lunches. (Education) SO5: Improve mother and child health and care. (Health) 13. Promote integrated management of acute malnutrition (IMAM) and treatment of malnutrition in health care facilities. (Health) Indicator 24: Percentage of health care facilities providing integrated management of acute malnutrition (IMAM). (Health) Component 3: Address basic causes of malnutrition and create an enabling environment for action on nutrition. 6. Limitations in governance, management and coordination. 7. Insufficient trained human resources. 8. Inadequate health and nutrition services. 51 9. Inadequate information system. 10. Inadequate financial system. 11. Vulnerability to disasters and emergencies. 12. Some social norms and behaviors hinder nutrition. 13. Gender inequality. Note that Component 3 Indicators are mostly Outputs. SO6: Strengthen institutional capacity, governance, management, and coordination. (Multisectoral) 14. Strengthen institutional capacity, governance, management, planning and coordination across multiple sectors at all levels. (Multisectoral) Indicator 25: Percentage of provincial and district nutrition committees (PNCs/DNCs) conducting at least 2 meetings per year. (Multisectoral) Indicator 26: Number of new policies, decrees and guidelines on promotion of nutrition developed and disseminated. (Multisectoral) SO7: Strengthen human resources. (Multisectoral) 15. Strengthen human resource capacity in all sectors at all levels. (Multisectoral) Indicator 27: Percentage of nutrition coordinators (nutrition focal points) at central, provincial, and district levels, who have received nutrition training. (Gender-disaggregate, women-men) (Multisectoral) Indicator 28: Percentage of all government staff working on nutrition at central, provincial, and district levels, who have received nutrition training. (Gender disaggregate, women-men) (Multisectoral) SO8: Improve health service delivery system for communities. (Health) 16. Promote the integration of nutrition into primary health care (PHC). (Health) Indicator 29: Percentage of villages declared as model nutrition villages and with nutrition convergence activities involving more than 1 sector. (Led by Health, with other sectors supporting) 52 SO9: Improve information management and use of evidence for decision- making. (Multisectoral, including Planning ministry) 17. Strengthen management and use of common results monitoring and evaluation framework, routine reporting, surveillance, research, surveys, and sharing of information and good practices. (Multisectoral) Indicator 30: Percentage of central level agencies, provinces and districts providing regular reports on nutrition by sector (health, education, agriculture). (Multisectoral) Indicator 31: Percentage of all government staff working on nutrition (central, provincial, district level) who have received training specifically on nutrition monitoring, evaluation, assessment, and learning (MEAL). (Gener-disaggregate, women- men) (Multisectoral) SO10: Improve financial management and increase investment. (Multisectoral, including Finance ministry) 18. Improve financial management, planning, tracking, and reporting of both government and official development assistance (ODA) funds across sectors at all levels. (Multisectoral) 19. Increase public and private domestic investment for nutrition aiming towards sustainability. (Multisectoral) Indicator 32: Percentage of central level agencies, provinces and districts providing regular financial reports on nutrition by sector (health, education, agriculture). (Multisectoral) Indicator 33: Percentage of total nutrition spending from domestic investment compared to official development assistance (ODA). (Multisectoral) SO11: Ensure effective preparedness and response to disasters and emergencies, and social protection. (Multisectoral, including Social Welfare ministry) 20. Develop and implement joint multisectoral contingency plans for delivery of timely, effective, and efficient nutrition interventions during emergencies, focusing on disaster- prone areas, responding to needs of affected populations. (Multisectoral) Indicator 34: Percentage of all government staff working on nutrition at central, provincial, and district levels, who have received training specifically on nutrition in disasters and emergencies. (Gender-disaggregate, women-men) (Multisectoral) 53 SO12: Scale up social and behavioral change communication (SBCC) for nutrition. (Multisectoral) 21. Develop and implement multisectoral plans for scaling up effective social and behavior change communication (SBCC). (Multisectoral) Indicator 35: Percentage of provinces and districts implementing multisectoral social and behavior change communication (SBCC) programs to promote nutrition behaviors and practices. (Multisectoral) SO13: Promote gender equity. (Multisectoral, including Lao Women Union) 22. Develop and implement multisectoral plans for promoting gender equity within nutrition interventions in all sectors at all levels. (Multisectoral) Indicator 36: Percentage of provinces and districts providing information about gender and nutrition and promoting gender equity within nutrition interventions. (Multisectoral) Total 13 Strategic Objectives Total 22 Interventions Total 36 Indicators 54 C. Interventions and Indicators by Sector (same information as above but by Sector) While this NPAN promotes multisectoral planning, it recognizes that implementation organized by sector remains the norm. This Table 5 shows the same information as Table 4 above, but organizes the contents by sector, for ease of reference. Table 6: Interventions and Indicators by Sector Interventions Indicators Health Sector 1. Promote women’s, maternal, infant, and young child nutrition. (Health) Indicator 1: Percentage of pregnant women receiving counseling for breastfeeding, food supplementation and child growth monitoring. (Health) Indicator 2: Percentage of newborns initiated on breastmilk within 1 hour after delivery. (Health) Indicator 3: Percentage of Infants under 6 months of age who are exclusively breastfed. (Health) 2. Provide micronutrients for target women and children. (Health) Indicator 4: Percentage of pregnant women who receive at least 90 iron-folic acid (IFA) tablets. Indicator 5: Percentage of women 12-25 years of age taking iron-folic acid (IFA) tablets weekly. (Health) Indicator 6: Percentage of children 6-59 months of age taking vitamin A supplementation in the past 6 months. (Health) 55 3. Improve and integrate hygiene, clean water, and sanitation systems; increase access and promote hygiene behaviors and practices. (Health/WASH) Indicator 7: Percentage of households using improved source of (clean and safe) drinking water. (Health/WASH) Indicator 8: Percentage of households using improved sanitation facility (latrine). (Health/WASH) Indicator 9: Percentage of households using handwashing facility with soap. (Health/WASH) Indicator 10: Percentage of kindergarten and primary schools using improved source of (clean and safe) drinking water. (Education/WASH) (Please note this Indicator is also listed under Education below) Indicator 11: Percentage of kindergarten and primary schools using improved sanitation facility (latrine). (Education/WASH) (Please note this Indicator is also listed under Education below) Indicator 12: Percentage of kindergarten and primary schools using handwashing facility with soap. (Education/WASH) (Please note this Indicator is also listed under Education below) 4. Prevent and control childhood diseases and provide deworming for children under 5 years of age. (Health) Indicator 13: Percentage of children 12-59 months of age taking deworming. (Gender-disaggregate, girls-boys) (Health) Indicator 14: Percentage of children under 5 years of age with diarrhea for whom treatment was sought at a health facility. (Gender-disaggregate, girls-boys) (Health) (LSIS) Indicator 15: Percentage of children under 2 years of age who have been fully immunized (Gender disaggregate, girls-boys) (Health) (LSIS) 10. Support the provision of micronutrient supplementation, deworming, immunization, and other health interventions in schools. (Joint Education and Health) (Please note this Intervention is also listed under Education below) Indicator 21: Percentage of secondary school girls taking iron- folic acid (IFA). (Joint Education and Health) Indicator 22: Percentage of primary school children receiving deworming. (Gender-disaggregate, girls-boys) (Joint Education and Health) 56 13. Promote integrated management of acute malnutrition (IMAM) and treatment of malnutrition in health care facilities. (Health) Indicator 24: Percentage of health care facilities providing integrated management of acute malnutrition (IMAM). (Health) 16. Promote the integration of nutrition into primary health care (PHC). (Health) Indicator 29: Percentage of villages declared as model nutrition villages and with nutrition convergence activities involving more than 1 sector. (Led by Health, with other sectors supporting) Total Health Interventions: 7, including 1 joint Health and Education Total Health Indicators: 19; of these, 3 are Education/WASH, and 2 are Education and Health, and are also listed under Education below Agriculture Sector 5. Promote production of diverse nutritious crops, vegetables, and fruits through clean agriculture. (Agriculture) Indicator 16: Number of families producing diverse crops, vegetables, and fruits through clean agriculture for consumption. (Agriculture) 6. Promote production of protein- and calcium-based foods from small animal-raising and fisheries. (Livestock and Fisheries) Indicator 17: Number of families raising small animals, fish, aquatic animals, and insects, or taking from natural sources, for consumption. (Livestock and Fisheries) 7. Promote community participation in planning, management, and sustainable use of natural resources and non-timber forest products (NTFPs). (Forestry) Indicator 18: Number of target villages which sustainably manage, use, and report on natural resources and non-timber forest products (NTFPs). (Forestry) 8. Promote the agriculture value chain system for nutrition. (Technical Extension and Agriculture Processing) Indicator 19: Number of production groups able to implement regular activities, such as food preservation, processing, marketing, and value improvement. (Technical Extension and Agriculture Processing) Total Agriculture Interventions: 4 Total Agriculture Indicators: 4 57 Education Sector 9. Promote nutritious and healthy diets through integration into the school curriculum, including small agricultural activities in schools. (Education) Indicator 20: Percentage of schools integrating nutrition into education curriculum (Education) 10. Support the provision of micronutrient supplementation, deworming, immunization, and other health interventions in schools. (Joint Education and Health) Indicator 21: Percentage of secondary school girls taking iron- folic acid (IFA). (Joint Education and Health) Indicator 22: Percentage of primary school children receiving deworming. (Joint Education and Health) 11. Promote hygiene, including clean water, sanitation, and handwashing in schools. (Education/WASH) Indicator 10: Percentage of kindergarten and primary schools using improved source of (clean and safe) drinking water. (Education/WASH) (Please note this Indicator is also listed under Health above) Indicator 11: Percentage of kindergarten and primary schools using improved sanitation facility (latrine). (Education/WASH) (Please note this Indicator is also listed under Health above) Indicator 12: Percentage of kindergarten and primary schools using handwashing facilities with soap. (Education/WASH) (Please note this Indicator is also listed under Health above) 12. Provide and promote nutritious school lunches. (Education) Indicator 23: Percentage of target schools providing and promoting nutritious school lunches. (Education) Total Education Interventions: 4, including 1 joint Education and Health Total Education Indicators: 7; of these, 3 are Education/WASH, and 2 are Joint Education and Health, and are also listed under Health above 58 Multisectoral 14. Strengthen institutional capacity, governance, planning, management, and coordination across multiple sectors at all levels. (Multisectoral) Indicator 25: Percentage of provincial and district nutrition committees conducting at least 2 meetings per year. (Multisectoral) Indicator 26: Number of new policies, decrees and guidelines on promotion of nutrition developed and disseminated. (Multisectoral) 15. Strengthen human resource capacity in all sectors at all levels. (Multisectoral) Indicator 27: Percentage of nutrition coordinators (nutrition focal points) at central, provincial, and district levels, who have received nutrition training. (Gender-disaggregate, women-men) (Multisectoral) Indicator 28: Percentage of all government staff working on nutrition at central, provincial, and district levels, who have received nutrition training. (Gender-disaggregate, women-men) (Multisectoral) 17. Strengthen management and use of common results monitoring and evaluation framework, routine reporting, surveillance, research, surveys, and sharing of information and good practices. (Multisectoral) Indicator 30: Percentage of central level agencies, provinces and districts providing regular reports on nutrition by sector (health, education, agriculture). (Multisectoral) Indicator 31: Percentage of all government staff working on nutrition (central, provincial, district level) who have received training specifically on nutrition monitoring, evaluation, assessment and learning (MEAL). (Gender-disaggregate, women- men) (Multisectoral) 59 18. Improve financial management, planning, tracking, and reporting of both government and official development assistance (ODA) funds across sectors at all levels. (Multisectoral, including Planning ministry) 19. Increase public and private domestic investment for nutrition aiming towards sustainability. (Multisectoral, including Planning ministry) Indicator 32: Percentage of central level agencies, provinces and districts providing regular financial reports on nutrition by sector (health, education, agriculture). (Multisectoral) Indicator 33: Percentage of total nutrition spending from domestic investment compared to official development assistance (ODA). (Multisectoral) 20. Develop and implement joint multisectoral contingency plans for delivery of timely, effective, and efficient nutrition interventions during emergencies, focusing on disaster-prone areas, responding to needs of affected populations. (Multisectoral, including Social Welfare ministry) Indicator 34: Percentage of all government staff working on nutrition at central, provincial, and district levels, who have received training specifically on nutrition in disasters and emergencies. (Gender-disaggregate, women-men) (Multisectoral) 21. Develop and implement multisectoral plans for scaling up effective social and behavior change communication (SBCC). (Multisectoral) Indicator 35: Percentage of provinces and districts implementing multisectoral social and behavior change communication (SBCC) programs to promote nutrition behaviors and practices. (Multisectoral) 22. Develop and implement multisectoral plans for promoting gender equity within nutrition interventions in all sectors at all levels. (Multisectoral, including Lao Women Union) Indicator 36: Percentage of provinces and districts providing information about gender and nutrition and promoting gender equity within nutrition interventions. (Multisectoral) Total Multisectoral Interventions: 8 Total Multisectoral Indicators: 11 Total Interventions: 22 Total Indicators: 36 60 Summary Sector Number of Interventions Number of Indicators Health 7, including 1 joint Health and Education 19, including 3 Education/WASH, and 2 Education and Health Education 4, including 1 joint Education and Health 7, including 3 Education/WASH, and 2 Education and Health Agriculture 4 4 Multisectoral 8 11 Total 22 Interventions (1 joint Health and Education is counted only once) 36 Indicators (5 Indicators in both Health and Education are counted only once each) Note: Intervention 10, on health and nutrition activities in school, is listed twice, under Health as well as Education. In addition, 5 Indicators are also listed under both Health and Education. To obtain the correct total and to avoid double-counting, the shared Intervention and the 5 Indicators should be counted only once each. The shared Intervention and Indicators emphasize the importance of intersectoral cooperation, particularly for nutrition-related activities in school. 61 XI. Key Results by Sector A. Health 11.1. Health is the leading sector in the nutrition program. As noted above, of the Ministry of Health’s 11 national impact-level indicators, 2 – stunting and wasting in children under 5 years of age – are nutrition indicators. All of the impact-level indicators in this National Nutrition Strategy and Plan of Action, such as low birth weight, anemia, underweight, and overweight, among children, adolescents, and women of reproductive age (15-49 years of age), are directly linked to health interventions. 11.2. In this NPAN’s Strategic Framework, the health sector is directly responsible for 7 Interventions (out of a total of 22 Interventions). These include maternal, infant and young child nutrition (MIYCN), micronutrients, children’s health, promotion of nutritious diets, and increasing access to health and nutrition services. Of the 7 Interventions, one is on WASH, and another, on school health, is a joint Intervention with the education sector. In addition to the Department of Hygiene and Health Promotion and the Centre of Nutrition, the Departments and Centers that will be involved in delivering outcomes under these Strategic Objectives are: Departments of Planning and Cooperation, Department of Communicable Disease Control, Department of Finance, Department of Food and Drug, Department of Healthcare and Rehabilitation, Department of Organization and Personnel, and Department of Training, Center for Maternal and Child Health, Center for Health communication Information and Education on Health, Center for Environmental Health and Water Supply (Nam Saat), and the Medical Products Supply Center (MPSC). 11.3. As described above, results in the nutrition sector are tied directly to broader results in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) and progress in implementing Primary Health Care (PHC) towards Universal Health Coverage (UHC). The delivery of nutrition interventions, such as the promotion of breastfeeding and healthy infant and young child feeding, the promotion of micronutrient supplementation, and growth monitoring, is primarily through an integrated package of RMNCAH services delivered at the community small hospital and village level. In this way, promotion of nutrition and addressing malnutrition goes together with development of community-based PHC. B. Education 11.4. Education is a critical sector in the nutrition program. This NPAN 2021-2025 features education sector contributions to nutrition that are more comprehensive, and more directly coordinated with the health sector, than during previous periods. The sector’s overall goal is to ensure that all young people in Lao PDR complete primary education, and as many young people as possible complete secondary education, equipping and preparing them to contribute to the development of society and the nation. Within this, the sector has the ability to mobilize extensive resources to educate young people, their families, and their communities, about the importance of nutrition, and to provide practical steps, such as micronutrient supplementation and deworming in schools, WASH in schools, school lunches, school gardens, and small agriculture activities in schools, to improve nutrition. In this 62 NPAN’s Strategic Framework, the education sector is responsible for 4 Interventions – of these, one is on WASH in schools, and another is a joint intervention with the health sector on health and nutrition activities in schools. 11.5. Education and Health. Schools are an important platform for the delivery of education about nutritious diets, micronutrient supplementation and deworming, and a broad range of health interventions directed at school children. These include immunization; prevention of tobacco, alcohol and drug use; sexual and reproductive health education, including prevention of cervical cancer; and development of water, sanitation, and hygiene systems and the promotion of healthy WASH practices. 11.6. Teaching About Nutrition. Schools are critical for children to increase their knowledge about dietary diversity, and to build healthy WASH practices. In this NPAN, the education sector will use the nutrition curricula developed under previous NPAN periods, continue to develop curricula designed for higher grades, train teachers in the use of these curricula, and ensure their use in teaching about nutrition in schools. 11.7. Food Supplementation. In Lao PDR as in many countries, there has been strong government and donor interest in continuing food supplementation for school children, i.e., school meals and school gardens. While there is limited evidence of the nutritional impact of school feeding, it is recognized that school feeding improves the school environment, keeps students in school, and provides an opportunity for positive involvement of the surrounding community. Food supplementation, through school meals and school gardens, will be used to provide practical application of the nutrition topics taught in the curriculum. C. Agriculture 11.8. As it deals with food production and food systems, agriculture is also a critical sector in the nutrition program. Families cannot improve their nutrition without the availability of, and access to, a sufficient amount of nutritious foods. Not surprisingly, previous NPANs focused the agriculture sector response almost wholly on agricultural production. While this NPAN continues to emphasize food production, steps are also taken for nutrition-sensitive agriculture programming to pay greater attention to dietary diversity and consumption and to the sector’s overall impact on the nutritional status of women and children. The sector’s overall goal is to strengthen agricultural production for sustainable development, and the sector plays a leading national role in rural development and poverty alleviation. Within this, the sector’s contribution to nutrition is to guarantee food security and the availability of nutritious food for consumption, ideally throughout the whole year. In this NPAN’s Strategic Framework, the agriculture sector is directly responsible for 4 Interventions, on food production, agricultural value chain, and natural resource management, including non- timber forest products (NTFP). 11.9. An important part of nutrition-sensitive agriculture is diversification of agricultural production. The sector promotes increased productivity of nutrient-rich crops, vegetables and fruits, fish, livestock, and non-timber forest products. The nutrition aim is to increase dietary diversity at the household level. Diversification of agricultural production also increases the ability to mitigate and cope with natural disasters and climate change risks. 63 While there is an increasing trend in villages in Lao PDR towards single cash crop production, it is important to balance this with diverse crop production and livestock raising. Village development committees and plans should not only aim to maximize overall and cash crop production, but also reflect nutrition concerns. Photo source: Plan International / SUN CSA in Lao PDR D. Other Sectors 11.10. This NPAN recognizes that addressing the basic causes of malnutrition requires creating an enabling environment, which in turn requires coordinated multisectoral action. For example, Improving planning, monitoring, and evaluation requires the efforts not only of the health, education, and agriculture sectors acting on their own, but also the active involvement of the Ministry of Planning and Investment. In a similar way, improving financial management for nutrition requires cooperation with the Ministry of Finance. 11.11. This NPAN adds new Strategic Objectives on nutrition in disasters and emergencies, and promoting gender equity. For the former (disasters and emergencies), it is important that nutrition actions are integrated within the plans and interventions of the Ministry of Labor and Social Welfare, the lead agency for the National Disaster Management Committee (NDMC). This situates the nutrition response within a broader social protection and social welfare agenda. For the latter (gender equity), it is also important that nutrition actions are integrated within the work of the Lao Women’s Union. Other mass organizations, such as the Lao Youth Union, have many comparative advantages and have much to contribute to nutrition efforts across multiple SOs and Interventions, including appropriate attention to nutrition during disasters and emergencies. For this reason, this NPAN features the involvement and engagement of sectors other than health, education, and agriculture. 11.12. Planning. In this NPAN, the Ministry of Planning and Investment (MPI) will be involved in Strategic Objective 9, information management and use of evidence for decision- making. Each of the central sectors in nutrition – health, education, and agriculture – has its own planning, monitoring, and evaluation system. For example, for the health sector, the system is DHIS2 (District Health Information System, version 2). DHIS2 reports on top-level nutrition indicators of stunting and wasting. However, nutrition requires M&E at a more detailed level of health reporting. In addition, many indicators are not specific to the health sector, but are across other sectors. The aim is that MPI will bring an overall view for effective coordination and use of the information system across sectors. Within the ministry, the National Information Platform for Nutrition (NIPN) project has developed extensive capacity to track and report on a range of multisectoral indicators, which should be integrated into the national response. MPI has a crucial role to play in planning and tracking domestic investment and official development assistance (ODA) for nutrition. 11.13. Finance. The Ministry of Finance will be engaged in Strategic Objective 10, improving financial management and increasing investment. Similar to the M&E area, each of the central sectors – health, education, and agriculture – has its own budgeting and financial 64 management and reporting process. The costing and financial reporting of the previous NPAN 2016-2020 has shown that it is important to integrate NPAN costing with the government budget process, and to increase transparency and accountability for both government funding and official development assistance (ODA) on nutrition. This can only be achieved with greater guidance and input from the Ministry of Finance. The aim is develop a clearer picture of the sources and uses of nutrition funds, from both government as well as ODA. This NPAN recognizes that, to date, ODA funds the large majority (90%) of nutrition actions in Lao PDR. It is important to balance this with greater domestic investment. However, a clearer picture is essential before moving forward. 11.14. Labor and Social Welfare. In this NPAN, the Ministry of Labor and Social Welfare will be involved in the implementation of Strategic Objective 11, preparedness and response to disasters and emergencies. Nutrition responses in such situations include diagnosis, referral, and treatment of severe acute malnutrition (SAM), and the provision of nutritious food supplementation for households in disaster-affected areas, particularly for pregnant and breastfeeding women, and children under 5 years of age. These responses should be integrated within overall disaster response efforts for communities, and hence require the leadership of the Ministry of Labor and Social Welfare. In addition, MLSW will bring a broader agenda of expanding and improving social protection and social insurance, in working with people, particularly women and children, in vulnerable situations. 11.15. Lao Women’s Union. The Lao Women’s Union will be involved in the implementation of Strategic Objective 13, promoting gender equity. Gender is a central critical issue for improving nutrition, and each sector has a responsibility for ensuring the promotion of gender equity within its nutrition interventions. For example, for the health sector, it is important to ensure that women and children have access to integrated health services at the community level. For education, secondary school girls require education about nutrition specific to their needs, as well as iron-folic acid supplementation. In agriculture, women’s greater influence and decision-making ability in production, food processing and marketing, management of local natural resources, and household consumption, are essential to improving nutrition outcomes. In cooperating with the Lao Women’s Union at appropriate levels (national, provincial, district, and village / community), sectors will ensure that all nutrition interventions maintain a focus on gender and maximize opportunities to advance women’s empowerment, development of women and girls, and gender equity. In turn, the involvement of the Lao Women’s Union in a variety of nutrition-related initiatives at various levels will enable LWU to develop a comprehensive gender and nutrition strategic approach. In addition, as noted above, other mass organizations, such as the Lao Youth Union, also have much to add towards implementation of numerous Strategic Objectives and Interventions. E. Importance of Multisectoral Action 11.16. This NPAN emphasizes multisectoral action to a much higher degree than before. The reasons for this are simple: In the conceptual framework, most of the basic causes of malnutrition – limitations in governance, management and coordination; inadequate trained human resources; vulnerability to disasters and emergencies; some harmful social norms and behaviors; and gender inequality – require action that is larger than can be 65 performed by any single sector. This is reflected in the strategic framework, where most of Component 3 and Strategic Objectives 6 to 13 all require multisectoral interventions. In addition, lessons from the previous NPAN Mid-Term Review (2018) and other reviews have shown that management and coordination issues are often more challenging and more difficult to address than technical issues within sectors. For these reasons, there is a greater emphasis and commitment to plan and deliver multisectoral action in this NPAN. 11.17. Here are some examples of specific areas that require multisectoral action: • The development of model nutrition villages requires actions not only in the health sector, but also in water, sanitation and hygiene (WASH), education, agriculture, and others. • Health, micronutrient supplementation, deworming, and WASH activities in schools require cooperation between education and health sectors. In general, the health sector provides technical guidance and input for these activities, but the activities are implemented by the education workforce (teachers). Objectives, targets, and reporting arrangements should be agreed and monitored jointly. • Measurement of dietary diversity and/or consumption requires cooperation between health and agriculture sectors. (If these activities occur in schools, they require cooperation between health and education sectors.) • While SO4 reaches secondary school girls, and SO5 provides health care for mothers and children, it is also important to reach adolescent girls who are not in school with nutrition education and supportive services, in the context of broader adolescent sexual and reproductive health. This requires cooperation between health and education agencies, as well as Lao Women’s Union and Lao Youth Union. • Food safety is an issue that involves both the agriculture sector (in terms of safe production, processing, and storage) and the health sector (in terms of safe preparation and cooking). • Increasingly, Lao PDR is faced with the challenge of how to promote a better food system and better food choices. The cheapest foods available in the market tend to be processed foods with low nutritional value. Social and behavior change communication (SBCC) needs to focus on improving food choices in families, and this cannot be addressed by any single sector, but instead by several working together – health, agriculture, education, Lao Women’s Union, Lao Youth Union, and others. XII. Implementation Arrangements Key characteristics of national nutrition policy and program implementation include: • High-level political commitment • Multisectoral coordination and convergence • ODA-funded projects with government counterpart agencies, as well as Government-funded projects • Local multisectoral solutions to reduce nutrition disparities • Prioritization at provincial, district, and village/community levels, and • Empowerment of communities 66 A. National Leadership, Management, and Multisectoral Coordination 12A.1. The National Nutrition Committee (NNC) provides the highest-level political leadership on nutrition in Lao PDR. NNC is chaired by the Deputy Prime Minister and includes Vice Ministers of Health, Education and Sports, Agriculture and Forestry, and others. NNC meets twice a year; one meeting coincides with the annual National Nutrition Forum. NNC is responsible for making high-level policy and strategy decisions, ensuring performance, receiving reports, and providing oversight. 12A.2. The Ministry of Health’s Department of Hygiene and Health Promotion (DHHP) serves as the Secretariat for NNC. The NNC Secretariat is headed by the Vice Minister of Health. DHHP, in its role as NNC Secretariat, periodically convenes multisectoral Technical Working Group meetings on various nutrition issues. The Centre of Nutrition, within DHHP, is responsible for providing support to the NNC Secretariat, and technical guidance and support to all agencies (in all sectors) working on nutrition. The NC collates nutrition reporting within the health sector, which is reported through MOH to the government. 12A.3. Multisectoral coordination mechanisms for nutrition will continue at national, provincial, district, and village / community level. This NPAN has a particular emphasis on increasing the quality of multisectoral coordination, so that it goes beyond simple sharing of information and plans, towards promoting policy and program convergence at appropriate levels. As detailed in this NPAN, aside from the central sectors of health, education, and agriculture, multisectoral coordination meetings will include, as relevant, the Ministry of Planning and Investment, Ministry of Finance, Ministry of Labor and Social Welfare, and Lao Women’s Union. They will also include key actors outside of government. These include, centrally, Lao civil society organizations (CSOs) and international non-governmental organizations (NGOs). They also include bilateral and multilateral development partners (donors), the private sector, and others. B. Key Actors and Partner Organizations, Including Civil Society 12B.1. This NPAN emphasizes the key sectors of health, education, and agriculture, and the important roles of the ministries of planning, finance, social welfare, and the Lao Women’s Union. The majority of nutrition programs and projects in Lao PDR continue to be funded by official development assistance (ODA), primarily bilateral and multilateral development partners (donors), supporting work implemented by Lao and international civil society organizations (CSOs) and non-governmental organizations (NGOs). In general, every ODA- funded nutrition project has one or more government counterpart agency/ies; this may be relevant departments of health, agriculture or education sectors, school, or similar, at the appropriate provincial, district, and/or village/community level/s. The idea is that ODA funds enable the delivery of activities to achieve nutrition outcomes, and at the same time, provide accompaniment for government counterpart agencies so that they are able to carry out their roles and responsibilities. 12B.2. The Scaling Up Nutrition Civil Society Alliance in Lao PDR (SUN CSA Laos) currently has over 70 member organizations; of these, 45 are national organizations, and over 20 are 67 international organizations. In 2020-2021, these organizations implemented 55 projects in 16 provinces, reaching over 1 million people. These projects ranged across health, education, agriculture, WASH, livelihoods, and women’s empowerment. The focus is on developing, in cooperation with government counterpart agencies, local multisectoral solutions to reduce nutrition disparities. 12B.3. Development partners (DPs) include both donors and implementing agencies. The European Union and UNICEF continue to co-chair the nutrition DP group, which meets regularly, aims to improve aid coherence and effectiveness, and works, through its members, to support, provide advice to, and learn from government actors. C. Sub-National Prioritization, Planning, Implementation, and Monitoring 12C.1. This NPAN encourages and promotes prioritization at each level of planning and implementation. For example, at national level, each sector should develop prioritization of provinces; likewise, at provincial level, each sector should identify and focus on priority districts. Nutrition problems are complex, and even provinces with, on average, good nutrition indicators, may include districts with poor indicators; similarly, at district level, some villages may have good nutrition status, and other villages may have worse status. 12C.2. Multisectoral Provincial Nutrition Committees (PNCs) are chaired by the provincial deputy governor, with PNC Secretariats led by the director of the provincial health office. Similarly, multisectoral District Nutrition Committees (DNCs) are chaired by the district deputy governor, with DNC Secretariats led by the director of the district health office. 12C.3. The roles and responsibilities of Provincial and District Nutrition Committees (PNCs/DNCs) include to lead the nutrition response in their area; coordinate planning, implementation, and monitoring of nutrition interventions; highlight the interventions within this NPAN that are local priorities for implementation; and identify and focus interventions on priority locations. In this way, PNCs/DNCs will engage with and guide key actors and partner organizations, including civil society organizations which are implementing nutrition projects. 12C.4. Because most nutrition action is funded by official development assistance (ODA) and implemented by civil society organizations (CSOs) and non-governmental organizations (NGOs), well-functioning PNCs/DNCs should learn from ODA projects. They will identify good practices and lessons learned in their area, and pursue opportunities to integrate these into regular practice funded by the government budget. D. Empowerment of Communities and Primary Health Care Approach 12D.1. This NPAN emphasizes nutrition work at the community level, i.e., working with families / households, and based in villages / communities. The very first Intervention in this NPAN is to promote maternal, infant, and young child nutrition (MIYCN). Within agriculture, the emphasis is on food production in order to increase availability and access for household consumption; and within education, the emphasis is on teaching students and improving knowledge and behaviors. Strategic objectives in relation to WASH, disasters and 68 emergencies, social and behavior change communication (SBCC), and gender equity, are focused on improving impact at the household and community levels. These strategic objectives will be achieved only if communities are empowered to understand the importance of nutrition and supported to make choices and to act in ways that improve their own nutrition. 12D.2. It is essential that the national nutrition program focuses on integrated delivery of nutrition services at the community level. In the health sector, for example, nutrition is delivered within broader maternal and child health (MCH) services. Nutrition programs should be an opportunity for small hospitals and village health volunteers to reach priority households not only with nutrition education and services, but with broad MCH services. Conversely, the nutrition program should be an opportunity for families and households to access a range of services in small hospitals. This corresponds to the Primary Health Care (PHC) approach, which is an essential cornerstone of achieving Universal Health Coverage (UHC). 12D.3. There are similar priorities and approaches in the education and agriculture sectors. In education, for example, schools are the basic unit for delivery of nutrition education and services, within broader efforts for health in schools, improving attendance and performance, and promoting positive education outcomes. In agriculture, services will focus not only on production for the market, but also for household consumption. This NPAN recognizes that, while high-level political leadership, effective management, and multisectoral coordination are all essential, nutrition is truly improved, and malnutrition reduced, because of actions taken primarily in communities, schools, households, and families. XIII. Monitoring and Evaluation System and Framework 13.1. The NPAN Monitoring and Evaluation (M&E) framework refers to the system by which the 8 Indicators for the Overall Goal (Section VIII above) and the 36 outcome- and output-level Indicators associated with Interventions and Strategic Objectives (Section X above) are tracked and reported. The aim is to ensure continuous tracking, analysis of progress, identification and sharing of lessons learned and challenges, replication and scale- up of good practices, and implementation of suggested improvements to nutrition programs and policies. 13.2. While the Centre of Nutrition has overall responsibility for nutrition M&E, the different components of the nutrition M&E framework are implemented through several methods, and under the responsibility of several actors. 13.3. The 8 Indicators for the Overall Goal (Section VIII) are the key global and national nutrition impact-level indicators – stunting, wasting, underweight, low birth weight, overweight, and anemia. In terms of the broader Reproductive, Maternal, Newborn, and Child Health (RMNCH) program, and Ministry of Health reporting to the National Assembly, these are health sector outcome-level indicators. Most of the Indicators for the Overall Goal (Section VIII) and a number of outcome- and output-level Indicators (Section X) are collected 69 through the periodic Lao Social Indicator Surveys (LSIS), first conducted in 2012 and then in 2017. 13.4. Among the 36 Indicators (Section X), the Health sector has the largest portion, with responsibility for 19 Indicators (Indicators 1 to 15, 21-22, 24, 29). At the same time, it should be noted that 5 of these 19 Indicators are held jointly by the Health and Education sectors (Indicators 10, 11, and 12 on WASH in schools, and Indicators 21 and 22 on micronutrients and deworming in schools). Some of these Indicators are collected by LSIS (every 5 years). Others can be collected through routine reporting (annually or more frequently). Where possible, the Indicators for the Overall Goal (Section VIII) and the health-related outcome and output Indicators (Section X, 19 Indicators) will be reported through the health sector’s information system District Health Information System 2 (DHIS2). For nutrition M&E data, the Ministry of Health maximizes the use of the existing health sector M&E data flow, as shown in Figure 6&7 below. Figure 7 : Monitoring and Evaluation Mechanism, Health Sector 70 Data accessible via web-based platform at central, provincial & district levels Administration line Coordination line Report system line reported quarterly reported monthly reported weekly reported every 3-5 years Health Center DHO DHIS2 WFP report HHP Unit DNC/ Secretariat FD Unit MCH Form (Data for DHIS2) 90 IFA; IFA-WRA; Vit A; Deworming; Early initiation BF; CU5 anthro; LBW; IMAM-OPD; Zinc-CU5D IMAM (SAM) Programme report - Admissions - Exit (cure/ default/ died) - MUAC screened (red/ yellow) - RUTF Stock-out District Dashboard Provincial Dashboard PHO HHP Section EHWS Center FD Section PNC/ Secretariat PNC-S Office CN MCH Center CHHE Center National Dashboard MoH DHHP HM Div. Adm. & Pln. Div FDD NNC/ Secretariat NNC-S Office HP Div PHC Div Survey reports (LSIS, FNSS..) Every 3-5 years DNC-S Office IVR for outreach reporting Village WASH report form - School - water (y/n) - School - toilets (y/n) - School - handwashing (y/n) - CLTS triggered (y/n) - Declared ODF (y/n) WASH Summary Report - Health facility - water (y/n) - Health facility - toilets (y/n) - Schools - water - Schools - toilets - Schools – handwashing - Villages w. CLTS triggered - Villages declared ODF - Villages declared with VHM & VNM District Hospital Provincial Hospital Village Figure 8: Health Sector Data Flow 71 Abbreviations Admin & Pln. Div Administration and Planning Division ພະແນກບໍລຫິານ ແລະ ແຜນການ CHHC Communication for Health and Health Education ສູນສ ື່ ສານເພ ື່ ອສຸຂະພາບ ແລະ ສຸຂະສກຶສາ CLTS Community Led Total Sanitation ສຸຂະພບິານທີື່ ຊຸມຊນົເປັນເຈົ ົ້າການ CN Center of Nutrition ສຸນໂພຊະນາການ CU5 Children Under 5 Years of Age ເດກັນ ົ້ອຍອາຍຸລຸື່ ມ 5 ປີ DHHP Department of Hygiene and Health Promotion ກມົອະນາໄມ ແລະ ສົື່ື່ ງເສມີສຸຂະພາບ DHIS2 District Health Information System 2 ລະບບົຂໍ ົ້ມູນຂື່ າວສານຂັ ົ້ນເມ ອງ 2 DNC District Nutrition Committee ຄະນະກາໍມະການ ດ ົ້ານໂພຊະນາການຂັ ົ້ນ ເມ ອງ DPC Department of Planning and Pooperation ກມົແຜນການ ແລະ ການຮື່ ວມມ EHWS Environmental Health and Water Supply ສູນອະນາໄມສິື່ ງແວດລົ້ອມ ແລະ ຈດັຫານໍ ົ້າ ສະອາດ FD Unit Food and Drug Unit ຂະແໜງອາຫານ ແລະ ຢາ FDD Food and Drug Department ກມົອາຫານແລະຢາ FNSS Food and Nutrition Security Survey ການສໍາຫຼວດກື່ ຽວກບັຄວາມໝັ ົ້ນຄງົດ ົ້ານ ອາຫານ ແລະ ໂພຊະນາການ HHP Unit Hygiene and Health Promotion Unit ຂະແໜງອະນາໄມ ແລະ ສື່ ງົເສມີສູຂະພາບ HM Div Health Management Division ພະແນກຄຸ ົ້ມຄອງອະນາໄມ HP Div Health Promotion Division ພະແນກສື່ ງົເສມີສຸຂະພາບ 90 IFA 90 Iron-Folic Acid (at least 90 tablets of Iron-Folic Acid for pregnant women within 3 months during pregnancy and after birth) ທາດເຫຼກັ-ອາຊດິໂຟລກິ 90 ເມດັ (ແມື່ ຍງິ ຖ ພາຕ ົ້ອງໄດ ົ້ຮບັ ທາດເຫຼກັ-ອາຊດິໂຟລກິ ຢື່ າງໜົ້ອຍ 90 ເມດັ ໃນໄລຍະຖ ພາ ແລະ ຫຼງັ ເກດີລູກ) IFA-WRA Iron-Folic Acid for Women at Reproductive Age ທາດເຫຼກັ-ອາຊດິໂຟລກິ ສໍາລບັແມື່ ຍງິໃນໄວ ຈະເລນີພນັ IMAM-OPD Integrated Management of Acute Malnutrition in Out Patient Department ການຄຸ ົ້ມຄອງການຂາດສານອາຫານແບບຮຸນ ແຮງເຊ ື່ ອມສານ ໃນພະແນກກວດເຂດ ນອກ IPHTM Institute of Public Health and Tropical Medicine ສະຖາບນັສາທາລະນະສຸກສາດ ແລະ ການ ແພດເຂດຮົ້ອນ IVR Interactive Voice Response ຄໍາຕອບໂດຍສ ື່ ສານຜື່ ານສຽງ LBW Low birth weight ນໍ ົ້າໜກັຕໍື່ າຫຼງັເກດີ MCHC Maternal and Child Health Center ສູນສຸຂະພາບແມື່ ແລະ ເດກັ MOH Ministry of Health ກະຊວງສາທາລະນະສຸກ MUAC Mid-Upper Arm Circumference ອົ້ອມຮອບວງົແຂນເທງິ 72 ODF Open Defecation ການຖື່ າຍຊະຊາຍ PHC Div Primary Health Care Division ພະແນກຮກັສາສຸຂະພາບຂັ ົ້ນຕົ ົ້ນ PHO Provincial Health Office ພະແນກສາທາລະນະສຸກແຂວງ PLW food supp. Physiological Loss in Weight ອາຫານເສມີສໍາລບັຜູ ົ້ທີື່ ນໍ ົ້າໜກັຫຼຸດ PNC Provincial Nutrition Committee ຄະນະກາໍມະການ ດ ົ້ານໂພຊະນາການຂັ ົ້ນ ແຂວງ RUTF Ready-to-Use Therapeutic Foods ອາຫານເສມີສໍາລບັປິື່ ນປົວໄດ ົ້ໃນທນັທ ີ TT Technical Team ຄະນະວຊິາການ VHM Village Health Model ບົ້ານສາທາລະນະສຸກຕວົແບບ VNM Village Nutrition Model ບົ້ານໂພຊະນາການຕວົແບບ WFP World Food Programme ອງົການອາຫານໂລກ Zinc-CU5D Zinc for Children Under 5 years of age with Diarrhoea ທາດສງັກະສໃີນເດກັນ ົ້ອຍລຸື່ ມ 5 ປີ ທີື່ ຖອກທົ້ອງ 13.5. Of the 36 Indicators, the Agriculture sector is responsible for 4 Indicators. While some of these Indicators can be collected through the sector’s routine reporting and information system, it is recognized that indicators in relation to consumption will require special data-gathering and reporting, which the sector is committed to do as its contribution to the nutrition program. These consumption indicators may be collected twice in the 5-year period of this NPAN, i.e., once at the beginning, and once at the end. For nutrition M&E data, the Ministry of Agriculture and Forestry has organized three reporting channels: i) within the ministry, from the district, to the province, up to the national level; ii) within technical departments; and iii) within individual projects, with reporting also linked to technical departments. Figure 9: Monitoring and Evaluation (M&E) Mechanism, Agriculture Sector https://www.researchgate.net/figure/Average-Physiological-Loss-in-Weight-PLW-for-all-Storage-Treatments-T1 fig5 262310666 73 13.6. Of the 36 Indicators, the Education sector is responsible for 7 Indicators. However, of these 7 indicators, 5 indicators are held jointly by the Education and Health sectors (Indicators 10, 11, and 12 on WASH in schools, and Indicators 21 and 22 on micronutrients and deworming in schools). It is important for the Education and Health sectors to agree how these Indicators will be collected, reported, and analyzed, to drive program and policy improvements. In addition to these 5 Indicators, the Education sector has a focus on 2 other Indicators – one is on integration of nutrition into the curriculum, and the other is on school lunches. These represent the major nutrition priorities of the sector. 13.7. In improving the existing curriculum and developing new ones for higher grades, the Research Institute on Education Sciences (RIES) of the Ministry of Education will work with concerned departments such as the Department of General Education and the Department of Teacher Training, as well as the Centre of Nutrition, Ministry of Health. For WASH in school, micronutrients and deworming in schools, and the school lunch program (SLP), school principals will provide reports to the District Education and Sports Bureau (DESB), Provincial Department of Education and Sports (PDES), and the Ministry of Education and Sports. For the school lunch program, the Village Education Development Committee (VEDC) is involved and cooperates in management and reporting. For micronutrients and deworming in schools, reports will be shared with small hospitals and district health offices (district hospitals). 13.8. There are 11 Multisectoral Indicators, reflecting the heightened emphasis in this NPAN on multisectoral actions compared to before. It will be important for the Centre of Nutrition to lead data collection, reporting, and analysis of these 11 Indicators. At the same time, it is to be noted that these 11 Multisectoral Indicators are outputs, not outcomes, and can be collected through simple frequency counts and basic analysis. It is envisioned that the Centre of Nutrition will convene periodic mulitsectoral nutrition meetings at the national level to enable data gathering and reporting on these Indicators to the National Nutrition Committee. 13.9. The previous NPAN 2016-2020 included a monitoring and evaluation (M&E) results framework dashboard for communication and dissemination. The aim of the dashboard is that key indicators are gathered by the relevant offices (central, provincial, and district) at appropriate times (monthly, quarterly, biannually, or annually), and reported both up to higher reporting levels as well as across to nutrition committee secretariats (national, provincial, and district). Every level has roles and responsibilities for nutrition M&E: village health volunteers and village chiefs; small hospital (health center) staff; sectoral units at the district level (health, agriculture, education); District Nutrition Committee (DNC); sectoral units at the provincial level (health, agriculture, education); Provincial Nutrition Committee (PNC); sectoral centers, departments, and ministries (health, agriculture, education); and the National Nutrition Committee (NNC) with its secretariat served by the Center of Nutrition. This M&E system requires broader coordination both within sectoral systems and across sectors at each level. Coordination is needed to develop an effective M&E system in the implementation of this NPAN during the period 2021-2025. 74 13.10. Role of NIPN. Lao PDR participates in the multi-country program National Information Platforms for Nutrition (NIPN), supported by the EU, UNICEF and other development partners. In Lao PDR, NIPN is led by 2 agencies, the Centre for Development Policy Research (CDR) within the Ministry of Planning and Information (MPI), and the National Institute for Economic Research (NIER). The aim of NIPN is to strengthen capacity to analyze data, to track progress, report, and improve programs for better nutrition. In Lao PDR, NIPN has developed a national nutrition profile, a nutrition data dashboard, and multiple research publications (for example, see Section IV.B.9 and the good practice example above). During the period of this NPAN 2021-2025, it is important that NIPN expands and intensifies technical assistance to the Centre of Nutrition and other agencies working on nutrition, so that nutrition data analysis and reporting can progressively move over to national systems. 13.11. It is important for the Centre of Nutrition to work with all stakeholders, including NIPN, to develop annual targets for the Indicators for the Overall Goal, and all of the outcome- and output-level targets. In many cases, these indicators require baseline values for 2021 or 2022 in order for targets to be set for later years up to 2025. It is also important for the Centre of Nutrition assist the different sectors in developing and maintaining systems for data gathering, and to monitor routine reporting from the different sectors on these indicators and targets. 13.12. This M&E chapter and Annexes 1 and 2 below replace the Common Results M&E Framework for Nutrition, which was drafted in 2018, but which did not include inputs from agriculture and education sectors. This M&E Framework is consistent with the 5-year plan (2021-2025) of the Centre of Nutrition, that was developed with assistance from USAID/RTI and USAID/CRS-ANRCB. 75 Annex 1. Indicator Definitions Indicators for Overall Goal Indicator for Overall Goal Definition Numerator Denominator Baseline Target 2025 Source Frequency Responsible 1. Prevalence of stunting in children under 5 years of age Prevalence of low height-for-age in children under five years of age (Height-for-age < =2 standard deviations (SD) of WHO Child Growth Standards median) Number of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard Total number of children under 5 years of age 33% (LSIS 2017) 26% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee 2. Prevalence of wasting in children under 5 years of age Prevalence of low weight-for-height in children under five years of age (Weight-for-height < =2 standard deviations (SD) of WHO Child Growth Standards median) Number of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard Total number of children 5 years of age 9% (LSIS, 2017) <5% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee 3. Prevalence of underweight in children under 5 years of age Prevalence of low weight-for-age in children under five years of age Number of children under age 5 who fall below (a) minus two standard deviations (moderate Total number of children under 5 years of age 21% (LSIS 2017) 13% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee 76 (Weight-for-age < =2 standard deviations (SD) of the WHO Child Growth Standards median) and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 4. Prevalence of children aged 6- 59 months with anemia Percentage of children aged 6-59 months with anemia (haemoglobin level < 11 g/dl at sea level) Number of children age 6-59 months with haemoglobin <11g/dl Total number of children aged 6- 59 months 44% (2006 MICS3- NNS) 30% Survey (MICS3- NNS, 2006; LSIS2 from 2017) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee 5. Prevalence of women of reproductive age with anemia Percentage of women of reproductive age (15-49 years of age) with anemia a. Non-pregnant women with haemoglobin level < 12 g/dl at sea level b. Pregnant women with haemoglobin level < 11 g/dl at sea level a. Number of non- pregnant women aged 15-49 years with haemoglobin <12g/dl b. Number of pregnant women aged 15-49 years with haemoglobin <11g/dl a. Total number of non-pregnant women aged 15-49 years b. Total number of pregnant women aged 15-49 years 40 % (LSIS 2017) 15% Survey (2006 MICS3- NNS; Indicator to be included in future surveys) Every 5 years MPI (LSB), MoH (DHHP) 6. Prevalence of low birth weight Percentage of live born infants weighing less than 2,500g at birth Number of last live births in the 2 years preceding the survey weighing below 2,500 grams at birth Total number of last live births in the last 2 years preceding the survey 6.5 % (LSIS, 2017) 8% Survey (LSIS1, 2, 3) Every 5 years7 MPI (LSB), MoH (DHHP), LSIS Committee 7. Prevalence of overweight in children under 5 years of age Percentage of children under five years of age with weight-for-height > =2 standard deviations (SD) of the WHO Child Number of children under age 5 who are above (a) two standard deviations (moderate Total number of children under 5 years of age 3.5% (LSIS 2017 ) ≤2% Survey (LSIS1, 2, 3) Every 5 years7 MPI (LSB), MoH (DHHP), LSIS Committee 77 Growth Standards median and severe) (b) three standard deviations (severe) of the median weight for height of the WHO standard 8. Percentage of infants under 6 months of age who are exclusively breastfed Percentage of infants 0– 5 months of age who are fed exclusively on breast milk and not receiving any other fluids or foods (with the exception of oral rehydration solution, vitamins, mineral supplements and medicines) Number of infants less than 6 months of age who are exclusively breastfed (with the exception of oral rehydration solution, vitamins, mineral supplements and medicines) (as reported by mother or caretaker during 24 hour period preceding survey) Total number of infants less than 6 months of age 45% (LSIS 2017) 60% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee Indicators for Health Sector Where possible, all indicators should be collected and reported through DHIS2. Outcome Indicator Definition Numerator Denominator Baseline Target 2021 Target 2022 Target 2023 Target 2024 Target 2025 Source Frequency Responsible Indicator 1: Percentage of pregnant women receiving Percentage of pregnant women receiving counseling for Number of pregnant women receiving counseling for Total number of pregnant women N/A 2020 N/A 50% 60% 70% >80% IQA (Quality Assesment), Annually MCHC, DPC, NC, Hospitals and MOH 78 counseling for breastfeeding, food supplementation and child growth monitoring breastfeeding, food supplementation and child growth monitoring at public health care facilities at all levels breastfeeding, food supplementation and child growth monitoring at public health care facilities at all levels DHIS2 Indicator 2: Percentage of newborns initiated on breastmilk within 1 hour after delivery. Percentage of infants born in the last 24 months who were put to the breast within one hour of birth Number of women with a live birth in the 2 years preceding the survey who put their last newborn to the breast within one hour of birth Total number of women with a live birth in the 2 years preceding the survey 39% (LSIS 2017) 43% 46% 50% 55% 80% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee Indicator 3: Percentage of infants under 6 months of age who are exclusively breastfed. Percentage of infants 0–5 months of age who are fed exclusively on breast milk and not receiving any other fluids or foods (with the exception of oral rehydration solution, vitamins, mineral supplements and medicines) Number of infants less than 6 months of age who are exclusively breastfed (as reported by mother or caretaker as being fed exclusively on breast milk and not receiving any other fluids or foods (with the exception of oral rehydration solution, vitamins, mineral supplements and medicines) during 24 hour period Total number of infants less than 6 months of age 45% (LSIS 2017) (40.4% LSIS 2011) 53% 55% 57% 59% >65% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee 79 preceding survey) Indicator 4: Percentage of pregnant women who receive at least 90 iron-folic acid (IFA) tablets Percentage of pregnant women who receive at least 90 iron-folic acid (IFA) tablets according to report during ANC in health care facilities or outreach Number of pregnant women who receive at least 90 iron-folic acid (IFA) tablets according to report during ANC Total number of pregnant women 25% (LSIS 2017) 66% 67% 68% 69% 70% Report Quarterly NC, MCHC Indicator 5: Percentage of women 12-25 years of age taking iron-folic acid (IFA) weekly. Percentage of women 12-25 years of age taking weekly IFA supplementation in target areas Number of women 12-25 years of age taking weekly IFA supplementation in target areas Total number of women 12- 25 years of age in target areas N/A 2015 DHIS2 data 30% N/A N/A N/A >70% DHIS2 Quarterly Health facility, DHO, PHO, MCH Indicator 6: Percentage of children 6 - 59 months of age taking vitamin A supplementation in the past 6 months. Percentage of children 6-59 months of age who received at least one high dose vitamin A supplement within the 6-month period preceding the survey Number of children 6-59 months of age who received at least one high dose vitamin A supplement within the 6-month period preceding the survey Total number of children 6- 59 months of age 59% (LSIS 2017) N/A N/A N/A N/A >80% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee Indicator 7: Percentage of households using improved source of (clean and safe) drinking water. (Health/WASH) Percentage of households observed to have or which report using improved source of drinking water. Any of the following types of supply: piped Number of households using improved source of drinking water Total number of households 83.9% (LSIS 2017) 91% 92% 93% 94% 95% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee 80 water (into dwelling, compound, yard or plot, to neighbour, public tap/standpipe), tube well/borehole, protected well, protected spring, and rainwater collection. Bottled water is considered as an improved water source only if the household is using an improved water source for handwashing and cooking. Indicator 8: Percentage of households using improved sanitation facility (latrine). (Health/WASH) Percentage of households observed to have or which report using improved sanitation facility (latrine). Defined as one that hygienically separates human excreta from human contact, including: improved flush or pour flush toilets (that flush to a Number of households using improved sanitation facility (latrine) Total number of households 73.8% (LSIS 2017) 81% 82% 83% 84% 85% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee 81 piped sewer system, septic tank, or pit latrine); ventilated improved pit latrines, pit latrines with slabs, and use of a composting toilet. Indicator 9: Percentage of households using handwashing facility with soap. (Health/WASH) Percentage of households observed to have or which report using handwashing facilities with soap. Number of households using handwashing facilities with soap. Total number of households 89.9% (LSIS 2017) 91% 92% 93% 94% 95% Survey (LSIS1, 2, 3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee Indicator 10: Percentage of kindergarten and primary schools using improved sources of (clean and safe) drinking water. (Education/WASH) Percentage of target schools observed to have or which report access to and using improved source of (clean and safe) drinking water as defined by national standards Number of target schools with access to and using improved sources of (clean and safe) drinking water Total number of target schools ECE: 77% Primary: 76% ECE 77% Primary 76,5% ECE 79% Primary 77% ECE 81% Primary 77,5% ECE 83% Primary 78% ECE: 85% Primary: 80% Reporting Annually Department of Preschool Education, Department of General Education and Target kindergarten primary schools,MES, CEHWS Indicator 11: Percentage of kindergarten and primary schools using improved sanitation (latrine). (Education/WASH) Percentage of target schools observed to have or which report access to and using improved sanitation facility (latrine) as defined by national standards Number of target schools with access to and using improved sanitation facility (latrine) Total number of target schools ECE: 77% Primary: 76% ECE 77% Primary 76,5% ECE 79% Primary 77% ECE 81% Primary 77,5% ECE 83% Primary 78% ECE: 85% Primary: 80% Reporting Annually Department of Preschool Education, Department of General Education and Target kindergarten primary schools, 82 MES, CEHWS Indicator 12: Percentage of kindergarten and primary schools using hand washing facility with soap. (Education/WASH) Percentage of target schools observed to have or which report having access to handwashing facilities with soap Number of target schools with access to and using handwashing facilities with soap Total number of target schools ECE: 54% Primary: 54% (2020 MES) ECE 54% Primary 60% (2020 MES) ECE 64.25% Primary 65% (2020 MES) ECE 74.5% Primary 70% (2020 MES) ECE 84.7% Primary 75% (2020 MES) ECE: 95% Primary : 80% Reporting Annually Department of Preschool Education, Department of General Education and Target kindergarten primary schools,MES, CEHWS Indicator 13: Percentage of children 12-59 months of age taking deworming. Percentage of children 12-59 months old who took their first round of deworming (helminthic) tablets in that year Number of children 12-59 months old who took their first round of deworming tablet in that year Total number of children aged 12-59 months in that year 67% (DHIS2 2018) 72% 74% 76% 78% 80% DHIS2 Annually DHHP Indicator 14: Percentage of children under 5 years of age with diarrhea for whom treatment was sought at a health facility. (Gender- disaggregate, girls- boys) Percentage of children 12-59 months old for whom mother/caregiver reported diarrhea in the past 2 weeks and sought treatment at a health facility or health care provider Number of children 12-59 months old for whom mother/caregiver reported diarrhea in the past 2 weeks and sought treatment at a health facility or health care provider Total number of children aged 12-59 months 49% (LSIS2) 57% 59% 61% 65% >70% Survey (LSIS3) Every 5 years MPI (LSB), MoH (DHHP), LSIS Committee Indicator 15: Percentage of children under 2 Percentage of children under 2 years of age (from Total number of children under 2 years of age who Total number of children under 2 years 75 (RMNCAH 80% 83% 85% 88% 90% DHIS2 Annually NIP, MCH Center, DHHP, MOH 83 years of age who have been fully Immunized (Health) birth to 23 months old) who have been fully Immunized (1dose of BCG, 3doses of OPV and Penta, 2 doses of measles- rubella vaccines) (disaggregated by gender : female, male) have been fully immunized of age Strategy Indicator 21: Percentage of secondary school girls taking iron- folic acid (IFA). (Joint Education and Health) Percentage of target secondary school girls taking iron-folic acid (IFA) Number of target secondary school girls taking iron- folic acid (IFA) Total number target secondary school girls during the school year N/A 60% 65 % 70 % 75 %  80% Reporting Annually Department of General Education and Target Secondary School, MoES, Centre of Nutrition Indicator 22: Percentage of primary school children taking deworming. (Joint Education and Health) Percentage of target primary school children taking deworming twice a year Number of target primary school children taking deworming twice in the past year Total number of target primary school children during the school year 91% (MES 2020) 92 % 93 % 94 % 95 % > 95% Reporting Annually Department of General Education and Target Secondary School, MoES, Centre of Nutrition Indicator 24: Percentage of healthcare facilities providing integrated management of Percentage of district hospitals providing integrated management of acute malnutrition Number of target district hospitals providing IMAM (SAM component) Total number of target districts N/A 30% 45% 60% 70% ≥80% DHIS2 Annually District hospitals DHO Nutrition Center DHCR 84 acute malnutrition (IMAM) (IMAM) in accordance with national IMAM guidelines in the total number of target provinces and districts. Indicator 29: Percentage of villages declared as model nutrition villages and with nutrition convergence activities involving more than 1 sector. (Led by Health, with other sectors supporting) Percentage of villages declared as model nutrition villages, regularly including convergence activities involving more than 1 sector Number of model nutrition villages Total number of target model nutrition villages N/A N/A N/A Disseminate guidelines and preparation 18 villages at least 1 village per province 148 villages at least 1 village per district 295 villages Reports Annual Centre of Nutrition Indicators for Agriculture and Forestry Sector Where possible, all indicators should be collected and reported by the regular agricultural sector reporting system. Outcome Indicator Definition Numerator Denominator Baseline Target 2025 Source Frequency Responsible Indicator 16: Number of families producing diverse crops, vegetables, and fruits through clean agriculture for consumption. Number of families producing diverse crops, vegetables and fruits, based on set quantity and standards for consumption. Targets are poor districts, Total number of families producing Total number of target poor families 971,900 families 1,176,260 families Reports Annual Department of Agriculture, Department of Rural Development & Cooperatives 85 (Agriculture) selected districts in 3 regions, selected villages in those districts. Indicator 17: Number of families raising small animals, fish, aquatic animals, and insects, or taking from natural sources, for consumption. (Livestock and Fisheries) Number of families raising small animals, fish, aquatic animals, and insects, or taking these from natural sources, based on set quantity and standards for consumption. Targets are poor districts, selected districts in 3 regions, selected villages in those districts. Total number of families producing Total number of target poor families 971,900 families 1,176,260 families Reports Annual Department of Livestock & Fisheries, Department of Rural Development & Cooperatives Indicator 18: Number of target villages which sustainably manage, use, and report on natural resources and non-timber forest products (NTFPs). (Forestry) Number of target villages which sustainably manage, use, and report on natural resources and non- timber forest products (NTFPs). NTFPs grown naturally or are grown by people, such as trunk (stem), vine, creeper, roots, shoots, leaves, flowers, fruits, seeds, bark, oil, resin, mushrooms, honey, and other medicinal herbs. Forest management plan refers to forest and land allocation in the village catchment area. Total number of target villages which sustainably manage, use, and report on natural resources and non-timber forest products (NTFPs) Total number of target villages (5 years) 1200 villages 1366 villages 2566 villages Reports Annual Department of Forestry Indicator 19: Number of production Number of production groups able to Number of established production groups able to implement activities Number of production groups 1,528 groups already 764 groups that have Reports Annual Department of Technical 86 groups able to implement activities based on their role, such as food preservation, processing, marketing, and value improvement. (Technical Extension and Agriculture Processing) implement regular activities, such as food preservation, processing, marketing, and value improvement, in the target villages. Production groups are volunteer gatherings of farmers for joint activities in cultivation, livestock, fisheries, food processing, and others. Value improvement can be throughout the production process from preparation and start, to processing, to selling and distribution, and consumption. based on their role already established established but not yet able to implement regular activities according to their role improved and are able to implement regular activities according to their role Extension and Agriculture Processing, Department of Agriculture, Department of Livestock and Fisheries, Department of Forestry Indicators for Education and Sports Sector Where possible, all indicators should be collected and reported through EMIS. Outcome Indicator Definition Numerator Denominator Baseline Target 2021 Target 2022 Target 2023 Target 2024 Target 2025 Source Frequency Responsible Indicator 20: Percentage of schools integrating nutrition into Percentage of target primary and secondary schools that have Number of target primary and secondary schools that Number of targets primary and secondary N/A 100% 100% 100% 100% 100% Reporting Annually Ministry of Education and Sports 87 education curriculum integrated nutrition into the education curriculum. report that have integrated nutrition into the curriculum schools Indicator 21: Percentage of secondary school girls taking iron-folic acid (IFA). (Joint Education and Health) Percentage of target secondary school girls taking iron-folic acid (IFA) Number of target secondary school girls taking iron-folic acid (IFA) Total number target secondary school girls during the school year N/A 60% 65 % 70 % 75 % >80% Reporting Annually Department of General Education and Target Secondary School, MoES, Centre of Nutrition Indicator 22: Percentage of primary school children receiving deworming. (Joint Education and Health) Percentage of target primary school children receiving deworming twice a year Number of target primary school children receiving deworming twice in the past year Total number of target primary school children during the school year 91% (MES 2020) 92 % 93 % 94 % 95 % >95% Reporting Annually Department of General Education and Target Secondary School, MoES, Centre of Nutrition Indicator 10: Percentage of kindergarten and primary schools using improved sources of (clean and safe) drinking water. (Education/WASH) Percentage of target schools observed to have or which report access to and using improved source of (clean and safe) drinking water as defined by national standards Number of target schools with access to and using improved sources of (clean and safe) drinking water Total number of target schools ECE: 77% Primary: 76% (MES) 77% Primary 76,5% 79% Primary 77% 81% Primary 77,5% 83% Primary 78% ECE: 85% Primary: 80% (MES) Reporting Annually Department of Preschool Education, Department of General Education and Target kindergarten primary schools,MES, CEHWS Indicator 11: Percentage of kindergarten and Percentage of target schools observed to have Number of target schools with access to Total number of target schools ECE: 77% 77% Primary 79% Primary 81% Primary 83% Primary ECE: 85% Reporting Annually Department of Preschool Education, 88 primary schools using improved sanitation (latrine). (Education/WASH) or which report access to and using improved sanitation facility (latrine) as defined by national standards and using improved sanitation facility (latrine) Primary: 76% (MES) 76,5% 77% 77,5% 78% Primary: 80% (MES) Department of General Education and Target kindergarten primary schools, MES, CEHWS Indicator 12: Percentage of kindergarten and primary schools using hand washing facility with soap. (Education/WASH) Percentage of target schools observed to have or which report having access to handwashing facilities with soap Number of target schools with access to and using handwashing facilities with soap Total number of target schools ECE: 54% Primary: 54% (MES 2020) 54% Primary 60% 64,25% Primary 65% 74,5% Primary 70% 84,7% Primary 75% ECE: 95% Primary: 80% (MES) Reporting Annually Department of Preschool Education, Department of General Education and Target kindergarten primary schools,MES, CEHWS Indicator 23: Percentage of target primary schools providing and promoting nutritious school lunches Percentage of target primary schools that regularly provide and promote nutritious school lunch to students according to the National Policy on Promoting School Lunch (2014) Number of target primary schools that report that in the past year, they provided nutritious school lunch to students at least once a month Number of target primary schools 51% (MES) 69% (MES) 69% (MES) 69% (MES) 69% (MES) >69% (MES) Reporting Annually Department of General Education and Target primary schools, MES Indicators for Multisectoral Interventions Note that most indicators for multisectoral interventions are outputs 89 Indicator Definition Numerator Denominator Baseline Target 2025 Source Frequency Responsible Indicator 25: Percentage of provincial and district nutrition committees (PNCs/DNCs) conducting at least 2 meetings per year. (Multisectoral) Percentage of provincial and district nutrition committees (PNCs/DNCs) conducting at least 2 meetings per year based on reports received by the Secretariat of National Committee on Nutrition. Number of provincial and district nutrition committees (PNCs/DNCs) conducting at least 2 meetings per year Total number of provincial and district nutrition committees NA 80% Regular reporting Quarterly Nutrition Committees at all levels Indicator 26: Number of new policies, decrees and guidelines on promotion of nutrition developed and disseminated. (Multisectoral) Number of new policies, decrees and guidelines on promotion of better nutrition, which have never been developed before, are developed and disseminated in 5 years (2021-2025) No numerator No denominator NA 30 Regular reporting Quarterly Centre of Nutrition Indicator 27: Percentage of nutrition coordinators (nutrition focal points) at central, provincial, and district levels, who have received nutrition training. (Gender- disaggregate, women- men) (Multisectoral) Percentage of nutrition coordinators (focal points) of 3 main sectors at central, provincial, and district levels, who have received nutrition training conducted by individual sector or jointly conducted Number of nutrition coordinators (focal points) of 3 main sectors at central, provincial, and district levels, who have received nutrition training conducted by individual sector or jointly conducted Total number of nutrition coordinators (focal points) of 3 main sectors at central, provincial, and district levels NA 70% Regular reporting Quarterly Centre of Nutrition Indicator 28: Percentage of all government staff working on nutrition at central, provincial, and district levels, who have Percentage of nutrition staff of 3 main sectors at central, provincial, and district levels, who have received nutrition training conducted by Number of nutrition staff of 3 main sectors at central, provincial, and district levels, who Total number of nutrition staff of 3 main sectors at central, provincial, and NA 50% Regular reporting Quarterly Centre of Nutrition (Ministry of Health, Ministry of Agriculture and Forestry, Ministry of 90 received nutrition training. (Gender- disaggregate, women- men) (Multisectoral) individual sector or jointly conducted have received nutrition training conducted by individual sector or jointly conducted district levels Education and Sports) Indicator 30: Percentage of central level agencies, provinces and districts providing regular reports on nutrition by sector (health, education, agriculture). (Multisectoral) Percentage of central level agencies, provinces and districts (Ministries, Provincial and District Offices) of 3 main sectors (health, education, agriculture) providing regular reports on nutrition Number of central level agencies, provinces and districts (Ministries, Provincial and District Offices) of 3 main sectors health, education, agriculture) providing regular reports on nutrition Total number of central level agencies, provinces and districts (Ministries, Provincial and District Offices) of 3 main sectors (health, education, agriculture) NA 100% Regular reporting Quarterly Centre of Nutrition (Ministry of Health, Ministry of Agriculture and Forestry, Ministry of Education and Sports) Indicator 31: Percentage of all government staff working on nutrition (central, provincial, district level) who have received training specifically on nutrition monitoring, evaluation, assessment and learning (MEAL). (Gender- disaggregate, women- men) (Multisectoral) Percentage of all government staff of 3 main sectors working on nutrition (central provincial, district levels) who have received training specifically on nutrition monitoring, evaluation, assessment and learning (MEAL) conducted by individual sector or jointly. Number of all government staff of 3 main sectors working on nutrition (central provincial, district levels) who have received training specifically on nutrition monitoring, evaluation, assessment and learning (MEAL) conducted by individual sector or jointly. Total number of all government staff of 3 main sectors working on nutrition (central provincial, district levels) NA 50% Regular reporting Biannual Centre of Nutrition (Ministry of Health, Ministry of Agriculture and Forestry, Ministry of Education and Sports) 91 Indicator 32: Percentage of central level agencies, provinces and districts providing regular financial reports on nutrition by sector (health, education, agriculture). (Multisectoral) Percentage of central level agencies, provinces and districts (Ministries, Provincial and District Offices) providing regular financial reports on nutrition by sector (health, education, agriculture). Number of central level agencies, provinces and districts (Ministries, Provincial and District Offices) providing regular financial reports on nutrition by sector (health, education, agriculture) Total number of central level agencies, provinces and districts (Ministries, Provincial and District Offices) of the 3 main sectors (health, education, agriculture) NA 70% Regular reporting Biannual Centre of Nutrition (Ministry of Health, Ministry of Agriculture and Forestry, Ministry of Education and Sports) Indicator 33: Percentage of total nutrition spending from domestic investment compared to official development assistance (ODA). (Multisectoral) Percentage of total nutrition spending from domestic investment compared to official development assistance (ODA) for 3 main sectors (health, education and agriculture) Nutrition spending from domestic investment for 3 main sectors (health, education and agriculture) Total nutrition spending for 3 main sectors (health, education and agriculture) 9% 15% Regular reporting Biannual Centre of Nutrition (Ministry of Health, Ministry of Agriculture and Forestry, Ministry of Education and Sports, Ministry of Planning and Investment, Ministry of Finance) Indicator 34: Percentage of all government staff working on nutrition at central, provincial, and district levels, who have received training specifically on nutrition in disasters and emergencies. (Gender- disaggregate, women- Percentage of all government staff of 3 main sectors working on nutrition (central provincial, district levels) who have received training specifically on nutrition in disasters and emergencies conducted by individual sector or jointly Number of all government staff of 3 main sectors working on nutrition (central provincial, district levels) who have received training specifically on nutrition in disasters and Total number of all government staff of 3 main sectors working on nutrition (central provincial, district levels) NA 80% Regular reporting Annual Centre of Nutrition (Ministry of Health, Ministry of Agriculture and Forestry, Ministry of Education and Sports, Ministry of Labor and Social Welfare) 92 men) (Multisectoral) emergencies conducted by individual sector or jointly Indicator 35: Percentage of provinces and districts implementing multisectoral social and behavior change communication (SBCC) programs to promote nutrition behaviors and practices. (Multisectoral) Percentage of provinces and districts implementing multisectoral social and behavior change communication (SBCC) programs to promote nutrition behaviors and practices Number of provinces and districts implementing multisectoral social and behavior change communication (SBCC) programs to promote nutrition behaviors and practices Total number of provinces and districts NA 80% Regular reporting Annual Centre of Nutrition (Ministry of Health, Ministry of Agriculture and Forestry, Ministry of Education and Sports) Indicator 36: Percentage of provinces and districts providing information about gender and nutrition and promoting gender equity within nutrition interventions. (Multisectoral) Percentage of provinces and districts providing information about gender and nutrition and promoting gender equity within nutrition interventions, especially in the 3 main sectors (health, education and agriculture) Number of provinces and districts in the whole country providing information about gender and nutrition and promoting gender equity within nutrition interventions, especially in 3 main sectors (health, education and agriculture) Total number of provinces and districts NA 80% of provinces and 80% of districts Regular reporting Annual Centre of Nutrition (Ministry of Health, Ministry of Agriculture and Forestry, Ministry of Education and Sports) 93 Annex 2. Interventions, Indicators, and Activities by Sector I. Health Sector Interventions/Indicators/Activities Target group Intervention 1. Promote women’s, maternal, infant, and young child nutrition (MIYCN). Indicator 1: Percentage of pregnant women receiving counseling for breastfeeding, food supplementation and child growth monitoring Indicator 2: Percentage of newborns initiated on breast milk within 1 hour after delivery. Indicator 3: Percentage of infants under 6 months of age who are exclusively breastfed. 1. Review, improve and develop strategy, policy, guidelines, manuals and plans on maternal, infant and young child nutrition (MIYCN). Mothers and children 2. Disseminate strategy, policy, guidelines, manuals and plans on maternal, infant and young child nutrition (MIYCN) for all relevant sectors at all levels. Relevant sectors and organizations at all levels 3. Conduct training on strategy, policy, guidelines, manuals and plans on maternal, infant and young child nutrition (MIYCN) at all levels for integration of infant and young child feeding (IYCF) in matenal and child health (MCH) services. Technical officers working maternal and child health services and nutrition for multiple sectors and related organizations at each level 4. Develop and disseminate short-term (3 months) curriculum on breastfeeding Relevant healthcare providers 5. Implement and monitor Decree on ‘’Food Products and Feeding Equipment for Infants and Toddlers”. Relevant healthcare providers 6. Celebrate National Nutrition Day (31 July) and International Breastfeeding Week (1-7 August). Relevant healthcare providers 7. Conduct training for counselors at all levels on breastfeeding. Relevant healthcare providers 8. Conduct training on maternal and child health (MCH) and nutrition for village health volunteers (VHVs), and Lao Women’s Union (LWU) village workers. Village health volunteers and women volunteers 9. Conduct activities to promote nutrition for social and behavioral change communication (SBCC). General population 10. Promote and monitor immediate breastfeeding after child birth and exclusive breastfeeding until six months of age in health care facilities at all levels. Relevant healthcare providers 11. Monitor child growth and provide counselling on infant and young child feeding (IYCF) in health care facilities at all levels, including through maternal and child health (MCH) mobile teams and at Nutrition Center. Mothers and children 12. Expand Baby Friendly Hospitals to promote breastfeeding. Target hospitals 13. Monitor and support activities at Baby Friendly Hospitals to promote breastfeeding. Target hospitals 14. Procure and provide basic equipment for counselling about infant and young child Target hospitals and 94 feeding (IYCF) for health care facilities and target communities. communities 15. Establish breastmilk bank model in target hospitals at central and provincial level. Target hospitals 16. Procure and distribute ready-to-use therapeutic food (RUTF) (F-75, F-100, Resomal) to treat children with severe acute severe malnutrition (SAM) within integrated management of acute malnutrition (IMAM). Children with severe acute malnutrition (SAM) Intervention 2. Provide micronutrients for target women and children. Indicator 4: Percentage of pregnant women who receive at least 90 iron-folic acid (IFA) tablets Indicator 5: Percentage of women 12-25 years of age taking iron-folic acid (IFA) weekly. Indicator 6: Percentage of children 6 - 59 months of age taking vitamin A supplementation in the past 6 months. 1. Review, improve national guidelines and manuals on micronutrient promotion and deworming. Target population 2. Disseminate national guidelines and manuals on micronutrient promotion and deworming. General population 3. Conduct re-training on national guidelines and manuals on micronutrient supplementation and deworming. Relevant healthcare providers 4. Review and update Decree (No.402) on salt iodization. Relevant sectors 5. Disseminate new decree on salt iodization. General population 6. Inspect and monitor salt quality in production factories and sites selling salt. Salt producing factories and selling locations 7. Assess the implementation of new decree on salt iodization. Relevant sectors 8. Develop guidelines and manuals on food fortification with vitamins and minerals. Relevant sectors 9. Disseminate guidelines and manuals on food fortification with vitamins and minerals. General population 10. Conduct training on guidelines and manuals on food fortification with vitamins and minerals. Relevant officers and business people 11. Monitor and evaluate guidelines and manuals on food fortification with vitamins and minerals.. Relevant sectors 12. Develop guideline manual on provision of micronutrient supplements in school between health and education sectors. Relevant sectors 13. Conduct training for all levels on national manual on micronutrient supplementation and annual planning of needs. Relevant sectors 14. Conduct training for all levels on guideline manual on food fortification with vitamins and minerals. Target population 15. Procure and distribute micronutrients: deworming tablets, Vitamin A, Vitamin B1, and iron-folic acid (IFA) for18 provinces. Target population 16. Procure necessary equipment for monitoring of salt quality. Monitoring team at each level 17. Promote iodized salt consumption and declare Lao PDR free of iodine deficiency diseases by 2025. General population 18. Conduct study on malnutrition in children and pregnant women (saliva, blood and urine tests on levels of iodine). Target population 19. Conduct survey on household iodized salt consumption and urine iodine level in pregnant women and school children (within LSIS 3 in 2022 or other survey) Target population 20. Conduct survey on iron-folic acid (IFA) deficiency in women of child-bearing age (12- 25 years old) and pregnant women (in first year to be used as baseline data). Women of reproductive age 95 Intervention 3: Improve and integrate hygiene, clean water, and sanitation systems; increase access and promote hygiene behaviors and practices. (Health/WASH) Indicator 7: Percentage of households using improved source of (clean and safe) drinking water. (Health/WASH) Indicator 8: Percentage of households using improved sanitation facility (latrine). (Health/WASH) Indicator 9: Percentage of households using handwashing facility with soap. Indicator 10: Percentage of kindergarten and primary schools using improved sources of (clean and safe) drinking water. (Education/WASH) Indicator 11: Percentage of kindergarten and primary schools using improved sanitation (latrine). (Education/WASH) Indicator 12: Percentage of kindergarten and primary schools using hand washing facility with soap. (Education/WASH) 1. Review, improve, and develop strategy, policy, manual and plan on integration of hygiene, clean water and sanitation system with nutrition. General population 2. Disseminate strategy, policy, manual and plan on integration of hygiene, clean water and sanitation system with nutrition, for all levels. General population 3. Conduct training for all levels on strategy, policy, manual and plan on integration of hygiene, clean water and sanitation system with nutrition. Relevant officers at each level 4. Develop coordination mechanism between sectors and organizations on integration of hygiene, clean water and sanitation system with nutrition. Relevant sectors 5. Develop information system and database on integration of hygiene, clean water and sanitation system with nutrition. Relevant sectors 6. Promote the use of clean and safe drinking water and water treatment in households. Relevant communities 7. Promote hygiene, latrine use, handwashing with soap and reduce/eliminate open defecation. General population 8. Improve water sources and water and latrine supply for poor and rural villages, particularly for priority focus areas. Priority focus areas 9. Construct clean and safe water areas, handwashing facilities and latrines in small hospitals and district hospitals in a way that prepares for responding to climate change, disasters, and emergencies. Target hospitals 10. Construct clean and safe water areas, handwashing facilities and latrines in schools. Target schools Intervention 4. Prevent and control childhood diseases, and provide deworming for children under 5 years of age. Indicator 13: Percentage of children 12-59 months of age taking deworming. Indicator 14: Percentage of children under 5 years of age with diarrhea for whom treatment was sought at a health facility. (Gender-disaggregate, girls-boys) Indicator 15: Percentage of children under 2 years of age who have been fully immunized 1. Develop guideline manual and coordination mechanism on prevention and control of diseases related to nutrition. Relevant sectors 2. Disseminate guideline manual on prevention and control of diseases related to nutrition. General population 3. Conduct training on guideline manual and mechanism on prevention and control of diseases related to nutrition. Relevant officers 4. Review and improve policy, guidelines and manuals on provision of deworming tablets for women after first trimester (first three months) of pregnancy. Relevant sectors 5. Conduct parasite prevalence survey among students and in the community. Target students and 96 communities 6. Increase immunization coverage for children under 5 years of age. Children under 5 years of age 7. Expand the network for elimination of open defecation in communities. General population Intervention 10. Support the provision of micronutrient supplementation, deworming, immunization, and other health interventions in schools. (Joint Health and Education) (Please note this Intervention is also listed under Education below) Indicator 21: Percentage of secondary school girls taking iron-folic acid (IFA). (Joint Education and Health) Indicator 22: Percentage of primary school children taking deworming. (Joint Education and Health) 1. Develop guideline manual and coordination mechanism on school health services between health and education sectors. Relevant sectors 2. Disseminate guideline manual on school health services between health and education sectors. Relevant sectors, organizations, and officers 3. Conduct training on guideline manual on school health services between health and education sectors. Relevant sectors, organizations, and officers 4. Improve information system, reporting system and information exchange between education, health, and related sectors. Relevant sectors 5. Promote and conduct joint activities on health and nutrition in schools. Relevant sectors 6. Train kindergarten teachers on infant and child care and growth monitoring in kindergartens, and support the schools to procure child growth monitoring equipment by themselves. Target schools and officers 7. Provide iron-folic acid (IFA) for secondary school female students and provide them health education and information on nutrition. Health and education sectors 8. Provide deworming tablets for students and provide health education and information on nutrition. Health and education sectors 9. Schools regularly monitor and report on provision of micronutrients and deworming tablets. Relevant schools Intervention 13. Promote integrated management of acute malnutrition (IMAM) and treatment of malnutrition in health care facilities. (Health) Indicator 24: Percentage of healthcare facilities providing integrated management of acute malnutrition (IMAM) 1. Conduct training on integrated management of acute malnutrition (IMAM) for all levels until village level. Relevant officers and target groups 2. Develop reporting system on integrated management of acute malnutrition (IMAM) for all levels until village level. Relevant officers, village health volunteers, and women volunteers 3. Supervise activities on integrated management of acute malnutrition (IMAM) regularly. Relevant officers 4. Provide knowledge on integrated management of acute malnutrition (IMAM) at the village level, screening for severe acute malnutrition (SAM) among children, and early referral for treatment in hospitals. General population 5. Assess treatment of malnutrition and IMAM regularly. Relevant officers 6. Develop national guideline manual on treatment of malnutrition. Relevant officers 7. Disseminate national guideline manual on treatment of malnutrition. Relevant officers 97 8. Continue to train staff on treatment of malnutrition for central and provincial hospitals. Target hospitals 9. Disseminate knowledge and promote nutrition education and treatment of malnutrition through diverse forms. General population 10. Review and improve manual on healthy and nutritious food. Relevant officers 11. Develop education media to prevent and control of non-communicable diseases, develop and promote video on physical exercise. Relevant officers Intervention 16. Promote the integration of nutrition into primary health care (PHC). Indicator 29: Percentage of villages declared as model nutrition villages and with nutrition convergence activities involving more than 1 sector. (Led by Health, with other sectors supporting) 1. Establish model nutrition villages focusing on all villages in priority areas meeting guideline manual criteria (Targets: 2022: at least 1 village per province / 2023: at least 1 village per district / 2025: at least 1 village per small hospital. Priority focus villages 2. Disseminate guideline manual on establishment of model nutrition villages for provinces, districts and villages. Relevant officers and target villages 3. Review, improve and promote nutrition activities at community level by integrating into maternal and child health (MCH) services, especially antenatal care (ANC) service, and child birth attended by skilled health care providers. Relevant officers 4. Develop guideline manual on community and mass organizations’ participation, especially Lao Women’s Union network at village level, for involvement in nutrition. Relevant officers 5. Conduct training on nutrition activities for village and women volunteers, and establish village women groups to work on nutrition. Target villages 6. Improve guideline manual on maternal and child health (MCH) and nutrition mobile service for villages in Zone 2 and zone 3. Relevant sectors 7. Conduct training on guideline manual on maternal and child health (MCH) and nutrition mobile service for villages in Zone 2 and Zone 3. Target officers 8. Implement maternal and child health (MCH) and nutrition mobile service for villages in Zone 2 and Zone 3. Target officers 9. Monitor maternal and child health (MCH) and nutrition mobile service for villages in Zone 2 and Zone 3. Relevant sectors Interventions: 7 (1 is joint with Education) Indicators: 19 (5 are also Education) Activities: 82 II. Agriculture and Forestry Sector Interventions/Indicators/Activities Target Group Intervention 5. Promote production of diverse nutritious crops, vegetables, and fruits through clean agriculture. (Agriculture) Indicator 16: Number of families producing diverse crops, vegetables and fruits through clean agriculture for consumption. (Agriculture) 1. Develop, improve and disseminate relevant policies and mobilize provincial and Relevant sectors 98 district levels to implement. 2. Build capacity and increase nutrition knowledge of agriculture technical staff (Integrate nutrition into teaching and learning curriculum of 5 colleges within the agriculture and forestry sector). Target people 3. Determine and allocate areas for agricultural production groups. Relevant sectors 4. Conduct training on agriculture techniques for small production groups and use of water from irrigation system. Target people 5. Conduct training on agriculture techniques to promote diverse household production. Target people 6. Promote technical production, the use of good seeds, allocation of land, water and fertilizers (biological fertilizers, preparation and improvement of soil, maintenance, and others). Relevant sectors 7. Monitor quality, inspect and certify production system. Relevant sectors 8. Conduct survey on production and consumption of diverse vegetables and fruits. Relevant sectors 9. Improve information and data collection system on production and consumption of vegetables and fruits. Target people Intervention 6. Promote production of protein- and calcium-based foods from small animal-raising and fisheries. (Livestock and Fisheries) Indicator 17: Number of families raising small animals, fish, aquatic animals, and insects, or taking from natural sources, for consumption. (Livestock and Fisheries) 1. Conduct survey in target villages to assess knowledge and awareness on production of poultry, pigs, goats, and consumption behavior in the community. Target people 2. Provide knowledge on animal raising for families, together with proper technical assistance, including the prevention of seasonal animal diseases. Relevant sectors 3. Increase knowledge of families on animal food production with proper technical assistance, i.e. family grass planting garden, production of animal food from agriculture waste disposal, and prevention of animal diseases. Relevant sectors 4. Develop and improve information system for animal raising, veterinary and fishery. Relevant sectors 5. Monitor and evaluate project implementation and develop plan to expand project activities to new target villages. Relevant sectors and Target people 6. Conduct situation and need assessment for fishery and other aquatic animals, manage natural water sources for fish and aquatic animals. Target people 7. Conduct training on animal raising, fishery and other aquatic animals, food processing from meat, fish, and aquatic animals, and participatory management. Relevant sectors and Target people 8. Promote agriculture support system and provide equipment and materials for small animal raising and fishery. Relevant sectors and Target people 9. Determine fish conservation zones and seasonal designated areas for animal hunting. Relevant sectors and Target people 10. Develop regulations on management of non-timber forest products, fishes and aquatic animals produced by the population in project target villages. Relevant sectors and Target people Intervention 7. Promote community participation in planning, management, and sustainable use of natural resources and non-timber forest products (NTFP). (Forestry) Indicator 18: Number of target villages which sustainably manage, use, and report on natural resources and non- 99 timber forest products (NTFPs). (Forestry) 1. Develop plan, allocate, manage, and use non-timber forest products at village level. Relevant sectors and Target people 2. Promote the development of utilization value and consumption of non-timber forest products at village level. Relevant sectors and Target people 3. Monitor and evaluate allocation, management and development of non-timber forest products. Relevant sectors 4. Develop and improve guideline manuals on growing and rehabilitation of non- timber forest products. Relevant sectors 5. Establish networks on management of non-timber forest products at village level (agriculture and forestry village team). Relevant sectors and Target people 6. Build capacity on management and utilization of non-timber forest products for villagers including ethnic groups. Relevant sectors and Target people Intervention 8. Promote the agriculture value chain system for nutrition. (Technical Extension and Agriculture Processing) Indicator 19: Number of production groups able to implement regular activities, such as food preservation, processing, marketing, and value improvement. (Technical Extension and Agriculture Processing) 1. Build capacity on management, administration, establishment of production groups, access to market, production techniques, quality food processing, food safety and building the value chain of agriculture products, for public sector, investors, and production groups. Relevant sectors 2. Improve, build small infrastructure, provide necessary materials and tools for sustainable food preparation and processing for production groups to promote year- round production. Relevant sectors and Target people 3. Review data and information to be used for determination of activities in the establishment of production groups. Relevant sectors and Target people 4. Establish and improve community markets, and organize appropriate and clean markets for each area. Relevant sectors and Target people 5. Improve and establish agriculture production groups for nutrition with good management system in 10 provinces, 20 districts, 60 villages and 140 groups, with 30% as model groups and 20% as model families. (Move to targets.) Relevant sectors and Target people 6. Support women’s participation in production and food processing groups so that at least 50% of members are women. Relevant sectors and Target people 7. Promote the use of technology and innovations in nutritious agriculture food product processing. Relevant sectors and Target people 8. Conduct study exchange visits. Relevant sectors and Target people 9. Build capacity on management and access to market for at least 50% of 140 agriculture groups to ensure that agricultural products are circulated regularly in community markets and organize special markets at least once a month based on conditions and convenience of each area. (Move figures to targets.) Relevant sectors and Target people 10. Promote the involvement of business, private investment, food security marketing, including green agriculture, organic plants and others. Relevant sectors and 100 Target people 11. Monitor and evaluate the implementation of activities. Relevant sectors Interventions: 4 Indicators: 4 Activities: 36 III. Education and Sports Sector Interventions/Indicators/Activities Target group Intervention 9. Promote nutritious and healthy diets through integration into the school curriculum, including small agricultural activities in schools, and other activities Indicator 20: Percentage of schools integrating nutrition into education curriculum 1.Continue to review and develop curricula of primary school (both formal and non-formal), in which nutrition has been integrated. Responsible committees at central, provincial, and district levels, and relevant schools 2.Review the curricula of lower and upper secondary schools (both formal and non-formal) in order to integrate nutrition as needed and appropriate Responsible committees at central, provincial, and district levels, and relevant schools 3.Develop teaching aids on nutrition, including posters, flash cards and other media. Responsible committee at central level 4.Capacity building for primary and secondary school teachers on nutrition. Primary school teachers in target areas 5.Develop collaboration between Research Institute for Education Science (RIES) and concerned authority within Ministry of Health in integration of nutritional knowledge in the curricula Responsible committee at central level 6.Capacity building for primary school teachers. Primary school teachers in target provinces 7.Capacity building on agriculture production for educational institutions at different levels including the ones that have a school lunch program (SLP) Responsible committees at central, provincial, and district levels, and relevant schools 8.Provide seeds, tools, and equipment for educational institutions at different levels including the ones that have a school lunch program (SLP) Primary schools in target areas 9.Capacity building on agriculture production in Community Learning Centres (CLCs) Primary schools in target areas 10.Conduct feasibility study on how to introduce cultivation techniques in schools with limited land area Primary schools in target areas with limited land area 11. Conduct needs assessment in schools to identify appropriateschool agriculture development Primary schools in target areas Intervention 10. Support the provision of micronutrient supplementation, deworming, immunization and other health interventions in schools. (Joint Education and Health) 101 (Please note this Intervention is also listed under Health above) Indicator 21: Percentage of secondary school girls taking iron-folic acid (IFA). (Joint Education and Health) Indicator 22: Percentage of primary school children receiving deworming. (Joint Education and Health) 1.Provide support for the distribution of Vitamin A among pre-school children (kindergartens). Pre-school children in target areas 2.Provide support for the distribution of iron supplement to female secondary school students Female students in target areas 3. Provide support for the distribution of deworming tablets to primary school students Children aged 5-14 years, in and out of school, in target provinces 4.Conduct training programme on the distribution of Vitamin A. Directors and teachers of target schools 5.Conduct training programme on iron supplement distribution. Directors and teachers of target schools 6. Conduct training programme on deworming distribution. Responsible committees at district level, directors, and teachers of target schools Intervention 11. Promote hygiene, clean water, sanitation, and handwashing in schools. (Education/WASH) Indicator 10: Percentage of kindergarten and primary schools using improved sources of (clean and safe) drinking water. (Education/WASH) Center for Environmental Health and Water Supply Ministry of Education Indicator 11: Percentage of kindergarten and primary schools using improved sanitation (latrine). (Education/WASH) 80% of kindergartens Indicator 12: Percentage of kindergarten and primary schools using hand washing facility with soap. (Education/WASH) 85% of kindergartens 1.Provide support and coordination in the provision of clean water in schools Schools in target provinces 2.Provide support and coordination to construct handwashing facilities in schools Responsible committees at central, provincial, and district levels, and relevant schools and communities 3.Provide support and coordination in the maintenance of latrines in schools Responsible committees at central, provincial, and district levels, and relevant schools and communities 4.Create a platform between schools and small hospitals to promote hygiene practices in schools including sharing health promotion materials Responsible committees at district levels, relevant schools, and communities 5.Develop WASH model schools. Responsible committees at central, provincial, and district levels, and relevant schools 6.Develop competition activities on WASH among primary school children. Target schools 7.Capacity building for provinces and districts on health promotion in pre-school institutions (kindergartens). Officers of pre-school education sections and pre-school education 102 units 8.Capacity building for school principals and teachers on assessment of WASH in schools. Directors of schools, teachers, and people responsible for monitoring WASH 9. Capacity building for pre-school administrators in provinces and districts on the use of WASH database. Officers of pre-school education sections and pre-school education units 10.Develop awareness raising activities using different types of media: poster, video, social media, others. Responsible committees at central and provincial levels Intervention 12. Provide and promote nutritious school lunches. (Education) Indicator 23: Percentage of target primary schools providing and promoting nutritious school lunches 1.Provide funding of 800 kip/per person/meal to pre-schools and primary schools for implementing school lunch programme (SLP). Kindergarten and primary school students in target areas 2.Provide food for implementing school lunch programme (SLP). Kindergarten and primary school students 3.Provide allowance for students of Ethnic Boarding School (EBS). Primary and secondary school students 4.Providie allowance for Special Education School (SES). Pre-school, primary, and lower secondary school students 5.Monitor and evaluate the implementation of school lunch programme (SLP). Provincial Education and Sports Department, District Education and Sports Offices, and target schools 6.Conducting training on programme management, data analysis and reporting for IEC, PESS, DESB staff members who are responsible for school meal programme (SMP). Responsible committees a provincial and district levels, and villages/schools 7.Improve reading room, materials and activities to encourage students to stay in schools during lunch time. Kindergarten and primary school students taking school lunch 8.Develop financial reporting system from the school to the ministry level. Schools, District Education and Sports Offices, and Provincial Education and Sports Departments 9.Conduct training courses on nutrition, food preparation, and food processing. Responsible committees at central, provincial, and district levels, village education development committees, and communities in target areas 10.Monitor and assess nutritional status in schools. Joint education and health monitoring team at central, provincial, and district levels 11.Develop guideline manual on the promotion of safe and nutritious food and beverage in schools. Responsible committee at central level 12.Conduct training programme for provincial-level staff on the use of the manual on safe and nutritious food and beverage. Responsible committee at provincial level 103 13.Capacity-building for remote communities on the implementation of school lunch programme (SLP). Responsible committees at central, provincial, and district levels, village education development committees, and communities in target areas 14.Capacity building for school principals and community leaders in School Lunch Programme (SLP) management. Responsible committees at central, provincial, and district levels, village education development committees, and communities in target areas Interventions: 4 (1 is joint with Health) Indicators: 7 (5 are also Health) Activities: 41 IV. Multisectoral Interventions/Indicators/Activities Intervention 14. Strengthen institutional capacity, governance, planning, management, and coordination across multiple sectors at all levels. (Multisectoral) Indicator 25: Percentage of provincial and district nutrition committees (PNCs/DNCs) conducting at least 2 meetings per year. (Multisectoral) Indicator 26: Number of new policies, decrees and guidelines on promotion of better nutrition developed and disseminated. (Multisectoral) 1. Review and improve policies, legal documents and strategic plans, and integrate food security and nutrition into 9th 5-year National Socio-Economic Development Plan (NSEDP). 2 .Improve roles and responsibilities, guidelines, and coordination mechanism for implementation of activities of nutrition committees at each level. 3.Disseminate roles and responsibilities and guidelines on the activities of nutrition committees at each level. 4.Review and improve policies and guidelines on nutrition promotion related to each sector. 5.Conduct regular meetings of national, provincial and district nutrition committees. 6. Regularly monitor and assess the work of national, provincial and district nutrition committees. Intervention 15. Strengthen human resource capacity in all sectors at all levels. (Multisectoral) Indicator 27: Percentage of nutrition coordinators (nutrition focal points) at central, provincial, and district levels, who have received nutrition training. (Gender-disaggregate, women-men) (Multisectoral) Indicator 28: Percentage of all government staff working on nutrition at central, provincial, and district levels, who have received nutrition training. (Multisectoral) 104 1.Review and improve legal documents, strategies, policies, and plans on capacity building for human resources who work on nutrition in relevant sectors. 2. Disseminate legal documents, strategies, policies, and plans on capacity building for human resources who work on nutrition in relevant sectors. 3.Integrate nutrition in teaching and learning curriculum of institutes and centers of relevant sectors. 4.Conduct training for nutrition coordinators of line sectors at central, provincial and district levels. 5. Conduct short-term training for management staff and officers working on nutrition in line sectors at central, provincial and district levels. 6.Conduct short-term training on promotion of nutrition and food security for related sectors at all levels. 7. Increase knowledge and skills of staff with work related to nutrition and food security with short-term training in-country and abroad (study visit, exchange of lessons, seminars, workshops and meetings). 8.Increase knowledge and skills of staff with work related to nutrition and food security with long-term training in-country and abroad (master and doctoral degrees). 9.Train staff responsible for nutrition research and surveillance. Intervention 17. Strengthen management and use of common results monitoring and evaluation framework, routine reporting, surveillance, research, surveys, and sharing of information and good practices. (Multisectoral) Indicator 30: Percentage of central level agencies, provinces and districts providing regular reports on nutrition by sector (health, education, agriculture). (Multisectoral) Indicator 31: Percentage of all government staff working on nutrition (central, provincial, district level) who have received training specifically on nutrition monitoring, evaluation, assessment and learning (MEAL). (Gender disaggregate, women-men) (Multisectoral) 1. Develop common results framework and report on results of implementation of food security and nutrition interventions for the secretariat of the National Nutrition Committee. 2. Develop guideline manual and tools on nutrition information, monitoring and evaluation system, including form and guideline to collect data on nutrition and food security. 3. Disseminate guideline manual and tools on nutrition and food security information, monitoring and evaluation system. 4. Conduct training on guideline manual and tools on nutrition and food security information, monitoring, and evaluation system for relevant staff at all levels. 5. Review, improve, and expand nutrition multisectoral surveillance system throughout the country (with clear and complete reporting) 6. Conduct regular reviews and monitor the progress of multisectoral nutrition indicators and results for 18 provinces 7. Assess needs and develop proposals and plans for nutrition and food security studies and research for line sectors. 8. Conduct training on nutrition and food security studies and research for line sectors. 9. Disseminate data and information (study findings). 10. Review and update mapping on management, finance, implementation of nutrition activities and related data at each level and various sectors. 11. Review and systematically improve multisectoral nutrition database. 12. Develop guidelines, manuals, mechanism, and tools on management of multisectoral nutrition 105 database. 13. Nominate responsible persons for information system, including management of multisectoral nutrition database. 14. Train staff of line ministries on monitoring and evaluation, including surveillance and information system. 15. Provide necessary equipment and materials for information system. 16. Establish website, data bank and nutrition bulletin. 17. Conduct meetings on lessons learned on multisectoral nutrition monitoring and evaluation. 18. Conduct mid-term review of NPAN 2021-2025. 19. Conduct end evaluation of NPAN 2021-2025. 20. Conduct field support supervision on the implementation of NPAN 2021-2025 for each sector at each level. 21. Conduct field support supervision on the implementation of NPAN 2021-2025 jointly between sectors at each level. 22. Exchange and use multisectoral nutrition data and information systematically and appropriately, especially from National Information Platforms on Nutrition (NIPN), DHIS2, SUN CSA, and others. 23. Conduct survey on nutrition status in women and children. 24. Conduct situation assessment and analysis of nutrition status by analyzing body mass index (BMI) in women and children aged 6 months to 2 years old and primary school students using isotope method. Intervention 18. Improve financial management, planning, tracking, and reporting of both government and official development assistance (ODA) funds across sectors at all levels. (Multisectoral) Indicator 32: Percentage of central level agencies, provinces and districts providing regular financial reports on nutrition by sector (health, education, agriculture). (Multisectoral) 1.Review, improve and develop guidelines and manuals on financial management. 2. Disseminate guidelines and manuals on financial management. 3. Conduct training on financial management, guidelines and tools. 4. Provide technical assistance to nutrition staff at provincial and district levels in order to be able to submit quality nutrition financial report. 5. Submit multisectoral nutrition financial reports regularly and systematically, every quarter at each level. Intervention 19. Increase public and private domestic investment for nutrition aiming towards sustainability. (Multisectoral) Indicator 33: Percentage of total nutrition spending from domestic investment compared to official development assistance (ODA). (Multisectoral) 1.Assess domestic investment in nutrition activities, including making a map of domestic investment. 2.Develop policy and guideline manuals on nutrition investment. 3. Disseminate policy and guideline manuals on nutrition investment. 4. Mobilize and advocate for increased investment in nutrition, food security, and food safety. 5. Request support from leaders and fund providers from public and private sectors, international donors and community. 6. Request Ministry of Finance to allocate government budget line for nutrition activities 7. Study the possibility of establishing a special joint investment between nutrtion and food security. 106 8. Monitor, evaluate, and report on nutrition domestic investment. Intervention 20. Develop and implement joint multisectoral contingency plans for delivery of timely, effective, and efficient nutrition interventions during emergencies, focusing on disaster-prone areas, responding to needs of affected populations. (Multisectoral) Indicator 34: Percentage of all government staff working on nutrition at central, provincial, and district levels, who have received training specifically on nutrition in disasters and emergencies. (Gender- disaggregate, women-men) (Multisectoral) 1.Implement mechanism and guideline manuals on readiness and response to disasters and emergencies, including those due to climate change. 2.Develop joint multisectoral strategies, policies, guidelines and tools for activities related to nutrition to respond to disasters and emergencies. 3. Conduct joint multisectoral rapid assessments and develop nutrition plans for disaster and emergency response. 4. Print and disseminate strategies, policies, guidelines and tools for activities related to nutrition to respond to disasters and emergencies. 5. Conduct training on strategies, policies, guidelines and tools for activities related to nutrition to respond to disasters and emergencies. 6. Conduct joint multisectoral field supervision and provide assistance to affected people during disasters and emergencies. 7. Monitor and reassess affected and malnourished women and children in disaster and emergency areas who were treated or referred. 8. Cooperate with projects with activities on disasters and emergencies to develop plans to provide assistance to areas with disasters and emergencies. 9. Integrate nutrition into climate change projects to prepare and respond to disasters and emergencies, including construction of basic infrastructure, water supply system and sanitation, and ensuring food security (food availability). 10. Develop joint multisectoral reports in disasters and emergencies. 11. Conduct joint multisectoral assessments of implementation of activities on disaster and emergency preparedness and response. 12. Develop plans to provide necessary materials, equipment, food supplements and medical food to use during disasters and emergencies. Intervention 21. Develop and implement multisectoral plans for scaling up effective social and behavior change communication (SBCC). (Multisectoral) Indicator 35: Percentage of provinces and districts implementing multisectoral social and behavior change communication (SBCC) programs to promote nutrition behaviors and practices. (Multisectoral) 1.Review, improve, and develop multisectoral strategies, policies, guidelines, and manuals on social behavioral change communication (SBCC), addressing all forms of malnutrition – under-nutrition, micronutrient malnutrition, and over-nutrition (overweight and obesity). 2. Disseminate multisectoral strategies, policies, guidelines, manuals on social behavioral change communication (SBCC) 3. Conduct training on manual on social and behavior change communication (SBCC) for sectors at each level, including for factories and workplaces. 4. Conduct training on nutritious food consumption for communities, including cooking demonstration. 107 5. Review, improve and develop all necessary tools on education and behavioral change in Lao and local languages. 6.Provide information, knowledge, practice or nutrition products for social and behavior change communication (SBCC). 7. Assess and conduct meetings to disseminate social and behavior change communication (SBCC) activities jointly across sectors. Intervention 22. Develop and implement multisectoral plans for promoting gender equity within nutrition interventions in all sectors at all levels. (Multisectoral) Indicator 36: Percentage of provinces and districts providing information about gender and nutrition and promoting gender equity within nutrition interventions. (Multisectoral) 1. Jointly develop multisectoral guideline manual on gender equity. 2. Jointly disseminate multisectoral guideline manual on gender equity. 3. Jointly conduct training on multisectoral guideline manual on gender equity. 4. Develop diverse nutrition tools on gender equity in Lao and ethnic languages to support the implementation of activities on gender equity, focusing on target populations jointly between relevant sectors, particularly Lao Women’s Union and other implementing organizations. 5. Produce and distribute information and media on gender equity for nutrition activities, including print and electronic materials through appropriate channels, including Ministry of Information, Culture and Tourism, mass organizations and relevant sectors. 6. Conduct joint survey on gender equity and social protection in nutrition, and develop and implement key activities to address the findings. 7. Evaluate and disseminate key results from implementation of activities on gender equity in nutrition Interventions: 8 Indicators: 11 Activities: 78 Summary Sector Interventions Indicators Activities Health 7 (1 is joint with Education) 19 (5 are also Education) 82 Agriculture and Forestry 4 4 35 Education and Sports 4 (1 is joint with Health) 7 (5 are also Health) 41 Multisectoral 8 11 78 Total 22 36 236 108 Annex 3. Examples of Projects of Members of Scaling Up Nutrition Civil Society Alliance (SUN CSA) (September 2020) These examples show the range and variety of Lao and international civil society organizations’ nutrition-specific and nutrition-sensitive projects. This is not a comprehensive list. Name of Organization Name of Project Province/s Start Date End Date Sector Target Group/s Donor/s Project Budget APL+ Care and support for People Living with HIV/AIDS Bokeo, Luang Prabang, Houaphanh, Luang Nam Tha 2011 2025 HIV/AIDS Mothers and children living with HIV/AIDS Global Fund LAK13 million / yr / province CoDA Various nutrition projects Savannakhet 2018- 2020 2020- 2021 Health, education, agriculture, LWU Villagers EU, MCNV, Plan, Oxfam, GIZ EUR219,825 for 1 project Catholic Relief Services (CRS) LEAPS II Savannakhet 2016 2021 Education including WASH School children US Department of Agriculture (USDA) US$28.4 million SDA Luang Prabang Sustainable Agriculture, Fisheries, and Food Security Luang Prabang 2020 2021 Agriculture Farmers GEF, UNDP US$20,000 World Renew ELECT Phongsaly 2019 2024 Health, education, agriculture, WASH, capacity building Remote area communities TEAR, others Approx US$300,000/yr World Renew GROW Luang Prabang 2020 2025 Health, education, agriculture, WASH, Remote area communities TEAR, others Approx US$200,000/yr 109 capacity building Plan International Integrated health, nutrition, and WASH projects Oudomxay and Salavanh 2020 2022 Health, WASH People in target villages Plan Approx US$1.4 million/yr SEADA Various organic farming and sustainable agriculture projects Vientiane Province, Luang Nam Tha, Xieng Khouang 2018 2021 Agriculture Farmers Bread for the World, Misereor, others NA SNV Enhancing Nutrition for Upland Farming Families (ENUFF) Houaphanh and Oudomxay 2016 2024 Nutrition, WASH, agriculture, governance Women of reproductive age, children under 5 years of age, household members, farmers Swiss Agency for Development Cooperation (SDC) Approx CHF15 million for total time period CHIas Partnership for improved resilience and improved nutrition security of Kado ethnic group, Kinae health center Salavanh 2021 2021 Nutrition Ethinc group children under 5 years of age EU EUR25,000 World Vision International Accelerating Healthy Agriculture and Nutrition (AHAN) Savannakhet, Salavanh, Attapeu 2019 2021 Health, agriculture, education, WASH, gender, nutrition Women, children, farmers, health workers EU and Department of Foreign Affairs and Trade (DFAT), Australia EUR11 million Helvetas Various nutrition projects Luang Prabang, Luang Nam Tha, Bokeo 2016 2024 Agriculture, health, natural resources EU EUR4 million for total time period 110 References 1. Lao Statistics Bureau (2018) Lao Social Indicator Survey II (LSIS 2017) 2. Bagriansky J and Voladet S (2013) The Economic Consequences of Malnutrition in Lao PDR: A Damage Assessment Report, commissioned by National Economic Research Insitute and UNICEF 3. World Bank (2021), www.worldbank.org 4. World Bank (2020) The World Bank in Lao PDR, www.worldbank.org 5. World Bank (2021) Lao Economic Monitor, www.worldbank.org 6. Centre for Development Policy Research (CDR), Ministry of Planning and Investment, COVID-19 Risks and Vulnerabilities in Lao PDR, published with UNICEF and UNFPA 7. UNICEF / WHO / World Bank Group (2021) Joint Malnutrition Estimates (JME) Levels and trends in child malnutrition: Joint Child Malnutrition Estimates: Key findings of the 2021 edition 8. World Health Organization (WHO) (2019), www.who.int 9. WHO (2017) Lao PDR Country Cooperation Strategy 10. National Information Platform for Nutrition (NIPN) (2020) Lao PDR National Nutrition Profile 11. National Institue for Economic Research (NIER) (2019) Nutrition Policy Landscape Analysis in Lao PDR (supported by NIPN) 12. Lao National Nutrition Committee (NNC) Secretariat (2018) Mid-Term Review of National Nutrition Strategy and Plan of Action 2016-2020 13. Lao National Nutrition Committee (NNC) Secretariat (2019) Operational Guidelines for Multisectoral “Convergence” Approach to Nutrition 14. Kurtishi S and Sisouphanthong V (2020) Review of Costing of the National Plan of Action for Nutrition 2016-2020, commissioned by EU and UNICEF http://www.worldbank.org/ http://www.who.int/