Integrated National Nutrition Strategic Plan 2013-2017

Hussain Rasheed State Minister Policy Planning and International Health Division Signature: Date: INTEGRATED NATIONAL NUTRITION STRATEGIC PLAN 2013-2017 No: Plan/23/-MoH/2016/02 1 | P a g e INTEGRATED NATIONAL NUTRITION STRATEGIC PLAN 2013-2017 1. Introduction Even though, Maldives has made significant progress in improving the nutrition status of the country, malnutrition still persists in the Maldives at an unacceptably high level. According to MDHS 2009, wasting is observed among10.6% of children under the age of five, 17.3% are underweight and 18.9% are chronically malnourished or stunted. The MDHS also found that 6% of under five children of Maldives are too heavy for their age. The Micronutrient survey conducted in 2007 showed that more than half the children 6 months to 5 years are vitamin A deficient (5.1% severely and 50.1% moderately deficient). Anaemia prevalence among children 6 months to 5years is 26%, with more than half the children (57%) iron deficient. Zinc and iodine deficiency are also at significant levels with 16% of children zinc deficient and 19% iodine deficient. Since 1992, Maldives has developed and implemented four nutrition plan of action. Through these plans, several interventions have been under taken to address malnutrition with a special focus on improving the nutrition status of the children under five years. These interventions resulted in the improvements of the nutrition status of the children. The fifth plan, Integrated National Nutrition Strategic Plan (INNSP) is a multi-sectoral plan which addresses the main challenges in the area of nutrition, food safety and food security. The key sectors responsible for implementing this plan are Trade, Fisheries, Agriculture, Health, Education, Social protection, National Planning and private sector engaged in food production, processing, supply and trade. 1.1 Previous National Nutrition Plans of Action The first national plan of action for nutrition, the National Nutrition Strategy (NNS 1992-1996) was developed in 1992, in response to the International Conference on Nutrition (ICN). This plan mainly focused on food security and primary health care. It also recognised the importance of nutrition 2 | P a g e assessment and during this period the Multiple Cluster Indicator Survey (MICS-I) was carried out which included the nutrition indicators. MICS I identified malnutrition as a serious public health problem in the country. This was the basis for a second National Nutrition Plan (NNP 1997 - 2000), developed with technical assistance from WHO, which focused on: 1. Food Security in Terms of Quantity and Quality 2. Prevention and Control of Micronutrient Deficiencies 3. Breast Feeding and Complementary feeding Practices 4. Nutrition Education 5. Continuous Monitoring of Growth and Nutritional Status of Young Children, Pregnant and Lactating Women 6. Provision of Nutritional Supplements to Mothers and Young Children of very low Social– Economic Groups 7. Advocacy on Nutritional Issues 8. Capacity Building 9. Monitoring, Surveillance and Evaluation MICS II conducted in 2001 showed improvements in most nutritional indicators. The GoM sought multi-sectoral inputs to review the NNP and to develop the National Nutrition Strategic Plan (NNSP 2002-2006). The NNSP included several interventions involving sectors outside health such as fisheries and agriculture, environment etc targeting the nutritional needs of school-age children, adolescents, women of childbearing age and older adults in addition to the children under five. The National Nutrition Strategic Plan (NNSP 2008-2010) also included the interventions targeting different age groups; however nutrition activities continued to focus mainly on under five children. During this period there was a continuation of the activities started during NNSP 2002-2006 which includes establishing Baby Friendly Hospital, Positive Deviance Programme and Online Nutrition Child Health Surveillance System. 1.2 Nutrition Situation According to MICS in 1996 the percentage of children under 5 years who are underweight was 43%. This figure when measured in MDHS using the revised WHO standard had declined to 17.3% in 2009. 3 | P a g e Similarly, stunting declined from 30% in 1996 to 18.9 % in 2009; and wasting declined from 17% in 1996 to 10.6 % in 2009. MDHS data indicate that higher proportion of boys (20%) are stunted compared to girls (17%). However, there is no statistically significant difference in the overall under nutrition status between girls and boys under 5 years. The data also shows that 6% of children under 5 years are overweight. Micronutrient survey conducted in 2007 showed that anaemia prevalence among children 6 months to 5years is 26%, with more than half the children (57%) iron deficient. Similarly more than half the children 6months to 5 years are vitamin A deficient (5.1% severely and 50.1% moderately deficient). Zinc and iodine deficiency though less severe is sever at levels of public health concern with 16% of children zinc deficient and 19% iodine deficient. The findings from the survey didn’t show a significant difference in micronutrient deficiencies between boys and girls. The dietary practices among adolescent are suboptimal. The results of Global School Health Survey (GSHS) indicate that only 22.7% of students usually ate a fruit two or more times per day and only 10.1% of students ate a vegetable three or more times per day. Male students (26.4%) consume more fruits and vegetables (12.6) than female students (19.3%- fruits) and (7.7% vegetables). The consumption of fruit and vegetables in Male’ is much lower compared to Atoll with fruit intakes 24.7% and vegetables intake 11.2% in Atoll and in Male’ fruit intakes is 5.2% and vegetables intake 7.5%. There is no statistical information to compare availability to this difference. However, stakeholder interview and focus group discussion indicate in Male’ availability of fruits and vegetables is not an issue. It is worth noting that 15% of the students indicated they eat from a restaurant three or more times a day. Among students only 24% of children engaged in physical activities for at least 60 minutes for 5 days in a typical week while 42% spend more than 3 hours per day engaged in sitting activities. Less students (39.6%) from Atolls engage in sedentary behavior than students (46.2%) from Male’. While this is so, about one third of the students are trying to lose weight by eating less (MoE, 2010). Malnutrition among reproductive aged women also continues to be of concern. MDHS showed that 46% of women 15-49 years are overweight or obese and only 8% are too thin with BMI less than 18.5. While overweight and obesity prevalence is high, micronutrient deficiencies are also high in this age group. According to the micronutrient survey, 15.4% women of reproductive age were found to be anaemic to some degree with 15.1% of them moderately anaemic in 2007; Micronutrient deficiencies follow the same pattern as in children with 38% of reproductive aged women were iron deficient and 44% vitamin A deficient. Zinc deficiency and iodine deficiency among reproductive aged women remained at 27% for both minerals. 4 | P a g e STEPS survey conducted in Male’ indicate that 46% of men are overweight and 17% obese. Health inequality analysis of this study showed that males and females in the poorest SES quintiles are more likely to be overweight and less likely if they are living in the 4th or richest, suggesting there is an inequality in the distribution of overweight between the poorest and richest SES quintiles. Within the Male’ population, the average weekly servings of fruit and vegetable is higher for males (7.0 and 6.4 per person respectively) than it is for females (5.8 and 5.4 per person respectively) and is more common amongst the richest SES quintiles (WHO, 2010). Education emerges as having a significant impact on consumption of fruit and vegetables, with those with secondary education and tertiary education being 2.4 and 3.3 times more likely than those with no education. This suggests that a health dietary intake is related more to levels of education than income, and may reflect the ability of better-educated people to absorb health education messages better (WHO, 2010). Based on the finding of the MDHS, MNS and GSHS it is evident that there is considerable regional variation in the nutrition status of the population. It is observed that overall nutrition status is better in the North region of the country. Both stunting in children under 5 years and Obesity among women is lower in this region compared to other regions. However, micronutrient deficiencies are more severe in North and South central regions of the country. Obesity among reproductive aged women is more common in Male’ and the regions closer to Male’. Male’ region has higher prevalence of poor infant and young child feeding practices such as delay in initiation of breast feeding and early initiation of complementary feeding. Similarly the practice of eating fruit and vegetables among adolescents is less common in Male’ compared to atolls. It can be concluded that although there is general awareness of healthy food, low functional knowledge of food and food items is one of the main underlying causes affecting care practices. II Integrated National Nutrition Strategic Plan (2013-2017) 5 | P a g e Prior to the development of the INNSP (2013-2017), a situation assessment was conducted to identify the causes of nutritional outcomes in the country. It was evident from the findings that nutrition situation in the country ranges from under nutrition among children, overweight and obesity among adults and micronutrient deficiency in all age groups. It is likely that obesity among children is also at levels of public concern. The situation assessment identified linkages of both food safety and food security issues, which must be addressed to sustain nutritional outcomes. Based on the findings of this assessment, an integrated food and nutrition framework was developed which is the basis for INNSP 2013-2017. 2.1 Goals and Objectives of INNSP (2013-2017) Although the goals of previous nutrition plans have not been fully met, considerable progress has been made in the reduction of Malnutrition in Maldives. Table II outlines the goals and targets of INNSP 2013-2017. 6 | P a g e Table II: Goal and targets of the Integrated National Nutrition Strategic Plan (2013-2017) RELEVENT POLICIES OF SAP GOALS TARGETS Policy 1: Strengthen commercial agriculture to reduce reliance on imported food and attain food Security. Policy 2: Facilitate the availability of agricultural inputs and accessibility to appropriate and environment friendly technology in all regions to promote sustainable agriculture farming systems Policy 3: Develop systems, networks and physical infrastructure for strengthening marketing and trade of agriculture produce and to encourage commercial agriculture Policy 5: Strengthen the institutional capacity to support the growth of agricultural sector (Agriculture sector) Policy 1: Expand the scope of the fisheries sector in the economy and diversify fish and marine products in a sustainable manner. Policy 3: Facilitate business development, trade and export Promotion in fisheries. (Fisheries sector) Ensure food security (availability and access to safe and nutritious food) throughout the country at household levels Prevalence of hunger reduced to <5%; Ratio of local agricultural produce to agricultural imports increased to -----; 80% of inhabited islands have all items of food basket available throughout the year; 10% of local and imported agricultural products are tested for chemical contamination; All items of food basket are tested for nutrient content; Prevalence of food borne diseases reduced to <5% ; Price controlled in 50% of items of food basket; 80% of eligible families provided with food subsidy; 7 | P a g e Policy 1: Restructure the revenue system towards direct taxation and rationalise the tariff regime to reduce burden on the poor Policy 3: Reduce barriers to a competitive market environment including costs of intermediation and barriers to entry for all sizes of business enterprises Policy 5: Make available affordable basic health insurance for all as well as control costs of medicine and food items. ( Affordable living costs) Policy 1: Strengthen health promotion, protection and advocacy for healthy public policies. (Health sector) Policy 1: Establish a social protection system that is preventive, promotive, and transformative. (Social protection) Policy 1: Strengthen health promotion, protection and advocacy for healthy public policies. (Health Sector) Policy 1: Establish a social protection system that is preventive, promotive, and transformative. Ensure care givers practice appropriate IYCF and dietary practices <10% of children under 5 years are undernourished and <15% stunted, <8% wasted <5% of children are obese >95% coverage of monthly growth monitoring in children under 2 years 60% of children exclusively breastfed for 6 months <10% of infants under 6 months fed with BMS 8 | P a g e (Social protection) Policy 1: Restructure the revenue system towards direct taxation and rationalise the tariff regime to reduce burden on the poor ( Affordable living costs) 75% of infants fed with the 3 IYCF practices <25% of infants fed with commercial baby food 60% of infants over 6months to 2 years fed with fruits and vegetables daily; All hospitals confirm to the 10 steps of a Baby Friendly Hospital All marketed BMS and packaged infant food conform to labelling and marketing regulations All food advertisements giving appropriate warnings Policy 1: Strengthen health promotion, protection and advocacy for healthy public policies.(Health sector) Reduce micronutrient deficiencies among children and women Prevalence of Vitamin A deficiency in children under 5 years reduced to 35% Prevalence of iron deficiency in children under 5 years reduced to 30% >95% of household use salt is adequately fortified with iodine >80% of children under 5 years provided with vitamin A supplementation Prevalence of anaemia in pregnant women decreases to 10% Policy 1: Strengthen health promotion, protection and advocacy for healthy public policies. (Health sector) Reduce obesity among adults 30% of young people and adults consume>400grams of fruit and or vegetables per day; 30% of adults’ daily energy intake from saturated fats is <10% ; 30% of adults’ daily energy intake from free sugars is <10% among adults; 60% of adults consume <5grams of salt per day 50% adults engaged in at least 20minutes of continuously physical activity for 5 days a week 9 | P a g e Policy 1: Align the Civil Service structure to the governing system of the country as required by the Constitution (2008) and ensure that political transitional arrangements are institutionalised. (Public Sector Reform ) Policy 5: Strengthen the institutional capacity to support the growth of agricultural sector (Agriculture Sector ) Policy 3: Build a competent, professional health service workforce (Health sector) Strengthen national coordination and capacity for food and nutrition security Food and nutrition council meet regularly and review progress annually; National food basket established; National food based dietary guidelines developed; Sector work plans of agriculture, fisheries, trade, health, social protection and education have outputs linked to the integrated food and nutrition framework; Referral and coordination procedure developed between local health service providers and public health institutions at atoll and national level; Atleast 2 staff trained upto postgraduate level in each of the 3 areas( food security, food safety and nutrition) working in respective national programmes at national level; Atleast 1 staff trained in nutrition and food safety (certificate 3/4) working in nutrition area at atoll level; Atleast 1 staff trained in fisheries, agriculture and food production (certificate 3/4)working in nutrition programme at national level; Policy 7: Strengthen agricultural statistics for results-based planning (Agriculture Sector) Policy 5: Promote research in fisheries and introduce fish breeding and productivity(Fisheries Sector) Policy 4: Build a culture of evidence based decision making within the Ensure appropriate data and information is available for decision making National food availability data published in statistical year book Food quality control data maintained and analyzed Local food consumption baseline data collected and analyzed Food borne disease surveillance system established and data analyzed annually Growth monitoring data analyzed annually Studies on food production and dietary practices conducted including a Total 10 | P a g e health system (Health sector) Dietary Study 2.2 Operationalizing the Integrated National Nutrition Strategic Plan 2013-2017 To ensure the effective implementation of the INNSP 2013-2017, the National Food and Nutrition Council (FNC) has been established. The main aim of this council is to ensure the food and nutrition policies and programmes are prepared and implemented with the involvement of the relevant sectors in order to achieve the national goals. There are two task groups under the council to provide the technical inputs. 1. Planning and monitoring task group: Develop budget action plans for food and nutrition programmes, monitor the progress of the programmes being implemented and collect food and nutrition statistics. The Secretariat for this group is Health Protection Agency (HPA). Other organization involve in this task group is department of national planning, ministry of health, ministry of Fisheries and Agriculture and ministry of Economic Development. 2. Enforcement and standards task group: Create awareness among the general population and service providers regarding food safety standards. It is also the task of this group to monitor how food standards and laws are being enforced and to address the challenges during the enforcement. This task group includes Ministry of Economic Development, Maldives Food and Drug Authority, Health Protection agency, Ministry of Fisheries and Agriculture and Maldives Customs Services. The secretariat for this group is Maldives Food and Drug authority. 2.3 Key action areas of INNSP The following are the key action areas outlined in the nutrition plan to address the nutritional deficiencies and to promote nutritional practices in Maldives. Details, including activities, expected outputs, lead and supporting implementing agencies are found in Annex I: INNSP 2013-2017 11 | P a g e ACTION AREAS 1. Supporting early start and early years The most critical step is to bring back focus of the nutrition programme to IYCF as recommended in the global strategy on IYCF, starting with foetal nutrition. This should specifically include reviving the support for BFHI and Code of BMS from the health system players, especially from paediatricians and obstetricians as well as professional associations of doctors, nurses and public health workers. This could include advocacy; providing training and BCC materials and tools on nutrition education during pregnancy, counseling and supporting mothers for exclusive breastfeeding and complementary feeding. Similarly support for micronutrient supplementation, Vitamin A and therapeutic zinc supplementation should be generated among health care providers while initiating interventions for educating mothers/caregivers. In addition to global strategy on IYCF, behaviour change communication interventions and micronutrient supplementation are identified as most cost effective interventions and recommended in the framework for scaling up nutrition by World Bank and partners. At the same time, priority needs to be given to revive school based nutrition and food safety programme, building on local experience, lessons learnt from other countries, including preschool nutrition programmes. Revival of the programme will require refresher training and establishing close relationship between school health programme and nutrition programme. 2. Facilitating easy access to nutritious and safe food At the outset priority needs to be given to develop a national food basket that meets the nutrition needs of the population, supported by food based dietary guidelines. Interventions in agriculture, fisheries and trade sectors should then be developed to ensure sustained availability, easy access and utilization of healthy and safe food commodities of the basket. Supporting community based producer organizations for production of foods specified in the food basket, price control measures for the items of the food basket and ensuring food subsidies provided through social protection mechanism covers items of the food basket are interventions that needs to be considered. 12 | P a g e The huge gaps in the food quality control system needs to be bridged with clear mechanism for post market surveillance linked to laboratory analysis and prevention and control of food borne diseases. This should address procedures for quality control of imported food including analysis for nutrients as well as microbial and chemical risk assessment, communication and management mechanism with public health, fisheries, agriculture and trade sectors. As the enactment of the draft food safety bill will empower the relevant institutions for enforcement of the relevant standards and procedures for quality control, plans to be made for developing enforcement capacity. Another critical component to be addressed is the establishing a coordinated food borne disease surveillance system linking disease and food components. 3. Provide information and communication for behaviour change Appropriate advocacy and lobbying interventions supported by relevant information for prioritizing nutrition as an integral part of national development is needed as an imperative measure. This should be coupled with mass media engagement to gain popular support for nutrition promotion. IEC and BCC interventions such as media campaigns and positive deviance interventions for specific target groups such as caregivers and consumers on appropriate feeding/eating, food safety and hygiene practices need to be developed to empower consumers on food choices that are rich in micronutrients, low in trans fats, saturated fats sugar and salt. Similar communication measures should be implemented to build knowledge of traders, agricultural workers and fishermen on chemical contamination of agricultural produces and compliance with labelling and marketing regulations. 4. Facilitating national coordination It is essential to develop a national food and nutrition coordination mechanism with clear mandate to harmonize policies, monitor progress and develop synergy between programmes of different agencies and charter an operational model to ensure functionality. As such a national food and nutrition council need to be established with task groups to support specific functions such as workgroups for awareness and consumer protection, planning and research, quality control etc. The structure of public health system needs to be defined in the context of local governance and health system reform. The implementation of the system should be facilitated with accepted working protocols with health service corporations for management and delivery of nutrition interventions in health 13 | P a g e facilities using PHC approach, reporting and supervision to public health officials in the island and atoll councils. Building the human resource capacity for food and nutrition interventions and retention of trained staff should be a priority. It is important to develop a medium term training plan covering both pre service and refresher trainings. At the same time, there is a need to review of the assessment methodology and criteria of students in the area of interpersonal communication in PHC and nursing course at FHS, to ensure graduates are competent in providing IYCF education to mothers at ANC/PNC and growth monitoring sessions. The implementation of community based interventions based on local context of the atoll or region, relevant to that atoll rather than the same programme for all atolls should be considered during the development of action plans. For example, in northern atolls more focus need to be given for interventions to address micronutrient deficiencies, while male and central atolls need focus on complementary feeding rather than exclusive breast feeding. The nutrition reports from atolls should be analyzed and used for prioritization of interventions for specific atolls. 5. Supporting policy with information and research: It is important to prioritize areas for research, including qualitative and systems research for improving operational efficiency of programmes. Some areas for research and analysis include food consumption and dietary studies; prevalence of food borne and food based diseases; extent of chemical contamination food and compliance to nutria requirements of the items of the food basket; underlying causes and determinants of feeding and eating behaviour; functional analysis of community based public health workers and health institution based nutrition staff. A mechanism for data collection, reporting, analysis and dissemination of information on four key areas of food security (availability, access, utilization and sustainability), food safety including compliance of food products to the nutritional standards required of the product and nutrition status of the population, especially children, across key sectors is essential for joint programme planning and monitoring. This includes sharing of existing data in different sectors, access to data sets, cross analysis and secondary analysis to monitor the situation and estimate impact. 14 | P a g e 6. Addressing determinants of nutrition: Advocacy and communication interventions should also be targeted to address the determinants of nutrition, specifically promotion of physical activity in all age groups. Specific school based interventions for physical activity promotion among secondary schools and women’s’ groups should be prioritized. Another area is improving hygiene practices especially in schools, educational establishments and public places. Advocacy for such services in land use planning and development and enforcement of sanitary standards are essential in this regard. Establishment of the national transport network will contribute to better distribution and availability of food. Aspects of transport of food should be considered in developing the transport network including transport of heat sensible and perishable food items. Finally education of girls should be facilitated to ensure better care practices of self and newborns and young children. Recent studies in the country shows that mothers educated beyond secondary have healthier care practices than mothers with primary education. 15 | P a g e Annex I: INNSP 2013-2017 S T R A T E G IE S ACTIONS OUTPUTS LEAD IMPLEM ENTING AGENCY PARTNER/ SUPPORTING AGENCIES MEANS OF VERIFICA TION ASSUMPTIOS 2013 2014 2015 2016 2017 ACTION AREA 1: SUPPORTING EARLY YEARS OF LIFE 1.1 Promote, Protect and Support Exclusive breast feeding Review status of BFHI hospitals, provide feedback to management of those facilities and the public and encourage to revive the initiative in hospitals status reviewed in 3 hospitals & feedback provided status reviewed in 6 other hospitals & feedback provided (cumulative 9 reviews) BFHI established in 2 new hospitals BFHI established in 2 new hospitals Status reviewed in 6 hospitals HPA Health facilities review reports; feedback meeting minutes technical staff and resources available; hospital management supportive Lobby support of health professional associations (Maldivian Medical Association, Maldives Nurses Association; Maldives Health Workers Union) for exclusive breast feeding Advocacy and sensitization meeting held with each health professional's association MMA,MNA and HWU Declaration for support obtained form MMA, MNA and HWU meeting held with MMA, MNA and HWU to discuss issues that needs to be addressed to increase support for EBF meeting held with MMA, MNA and HWU to discuss issues that needs to be addressed to increase support for EBF meeting held with MMA, MNA and HWU to discuss issues that needs to be addressed to increase support for EBF HPA Maldivian Medical Association (MMA), Maldives Nurses Association (MNA), Health workers Union(HWU) meeting minutes with the association s/ union participation and support of key persons makers form the profession Create a advocacy/ lobby group among doctors, nurses and within the community who would act as mentors and advisors to promote recommended IYCF practices at health At least 5 lobby group members identified lobby groups members actively advocate EBF in health facilities and community additional 5 lobby group members identified lobby groups members actively advocate EBF in health facilities and community lobby groups members actively advocate EBF in health facilities and community HPA MMA, MNA, HWU, NGOs list of lobby group members and their meeting minutes health professionals interested and supportive 16 | P a g e facilities Provide refresher TOT to concerned management and technical staff of all hospitals on the 10steps of BFHI TOT provided to identified focal points from all registered hospitals - - HPA Health facilities training records staff available for training Organize ANC/PNC clinics or consultation sessions to allow provision of information and education on exclusive breast feeding and recommended IYCF practices ANC/PNC clients receive IYCF information in hospitals ANC/PNC clients receive IYCF information in hospitals ANC/PNC clients receive IYCF information in hospitals ANC/PNC clients receive IYCF information in hospitals ANC/PNC clients receive IYCF information in hospitals Health Facillities Health facilities, HPA materials provided & info given at ANC visits at health facilities health service providers supportive; technical staff available Provide refresher training to nurses and doctors working in obstetrics paediatrics on supporting exclusive breast feeding and IYCF counselling Refresher training provided in 3 hospitals Refresher training provided in 6 other hospitals (cumulative 9 hospitals) Refresher training provided in 6 other hospitals (cumulative 15 hospitals) Refresher training provided in 6 other hospitals (cumulative 21 hospitals) HPA Health facilities, HPA training records of health facilities health service providers supportive; 17 | P a g e Provide IYCF and exclusive breast feeding counselling training to nurses and primary health care workers and conduct skill assessment in this area during nursing and PHC pre service courses conducted in the country Skill assessment on IYCF counselling conducted as part of PHC training at FHS Skill assessment on IYCF counselling conducted as part of nurses training at FHS - Nurses and PHC Training institution s Maldives National University (MNU), HPA skill assessment records technical expertise available; support from course director/dean Develop national IYCF guidelines including breast feeding and infant feeding by HIV positive mothers and in emergency/disaster situations IYCF guidelines drafted IYCF guidelines enforces and disseminated to health care providers - HPA Health facilities guideline document technical expertise available Advocate for extension of maternity leave to at least 6months to enable exclusive breast feeding and care of newborns in the first 6moths of life advocacy meetings held with PO, HRC, CSC and parliamentari ans advocacy meetings held with PO, HRC, CSC and parliamentar ians MoH civil service association, HPA, human rights commission meeting minutes policy makers, law makers participation and support 18 | P a g e Obtain support of CBOs and community leaders for promotion of exclusive breast feeding CBOs/ community leaders identified in 10 additional islands to promote EBF CBOs/ community leaders identified in 15 additional islands to promote EBF (cumulative 25 islands) CBOs/ community leaders identified in 15 additional islands to promote EBF (cumulative 40 islands) CBOs/ community leaders identified in 15 additional islands to promote EBF (cumulative 55 islands) HPA CBO,NGO, council offices record of CBOs supporting EBF technical expertise available; CBOS interest; resources available; 1.2 Enforce national regulations on marketing of BMS and infant foods Conduct awareness/sensitization sessions targeting health care professionals on the international code of BMS and the national regulation with regard to roles and responsibilities of health care providers and facility mangers One seminar held at central level Two seminars held targeting health services corporations Two seminars held targeting health services corporations HPA Health facilities,nurse association, MFDA,NGO report of seminars technical expertise available; resources available; health care providers supportive Lobby support of policy makers, paediatricians and child rights activists to enforce the national regulation on BMS Meeting held with policy makers at MOH and MoED Meeting held with policy makers at MOH and MoED - MFDA HPA, MMA, MNA, HWU meeting minutes participation and support of policy makers, law makers and lobby group members Establish procedures for enforcement- product registration, inspection and post market surveillance of BMS and infant foods SOP for product registration established SOP for inspection and PMS established - - MFDA MED, CUSTOMS, council offices SOP documents stakeholder support and good coordination 19 | P a g e Sensitize importers, wholesale and retailers on the national regulation on BMS sensitization seminar held for importers and traders sensitization seminar held for importers and traders sensitization seminar held for importers and traders MFDA MFDA,MED meeting minutes/rep ort participation of importers and traders; limited inference form BMS manufacturing industry Conduct awareness/training sessions targeting enforcement officers of MFDA, customs, trade and public health on the national regulation on BMS and enforcement procedures Training session conducted for enforcement officers in Male and other international ports Refresher training session conducted for enforcement officers MFDA HPA/MED customs/police training records staff available for training; city/atoll/islan d councils supportive Create public awareness on the objectives and requirements of the national regulation on BMS Information provided through radio programmes Leaflet produced on the regulating BMS Information provided through radio and TV programmes Information provided through radio and TV programmes Information provided through radio and TV programmes MFDA HPA/ customs/ chamber/ central and atoll councils broadcast records resources available; media supportive 20 | P a g e 1.3 Improve nutrition status of young women and pregnant mothers Conduct nutrition camps targeting adolescent girls and young women secondary schools and higher education institutions monitor their nutrition status, including anaemia status and provide them nutrition advice and information Nutrition camp conduced in 6 schools/instit utions Nutrition camp conduced in 10 schools/insti tutions Nutrition camp conduced in 15 schools/instit utions Nutrition camp conduced in 20 schools/instit utions MoE HPA, schools, MNU event report MoE,HPA and health service providers supportive Conduct nutrition assessment as part of ANC and provide dietary advice from early pregnancy through ANC clinics and visits Nutrition advice given to mothers at ANC visits in 3 hospitals/clini cs Nutrition advice given to mothers at ANC visits in 6 additional hospitals/clini cs (cumulative 9 facilities) Nutrition advice given to mothers at ANC visits in 6 additional hospitals/cli nics (cumulative 15 facilities) Nutrition advice given to mothers at ANC visits in 6 additional hospitals/clini cs (cumulative 21 facilities) Nutrition advice given to mothers at ANC visits in 6 additional hospitals/clini cs (cumulative 27 facilities) HPA Health facilities, HPA, council offices ANC records health service providers supportive; trained staff in place 21 | P a g e Obtain support of CBOs and community leaders for nutrition promotion and support of pregnant women CBOs/ community leaders identified in 10 islands to promote nutrition of pregnant women CBOs/ community leaders identified in 15 additional islands to promote nutrition of pregnant women (cumulative 25 islands) CBOs/ community leaders identified in 15 additional islands to promote nutrition of pregnant women (cumulative 40 islands) CBOs/ community leaders identified in 15 additional islands to promote nutrition of pregnant women (cumulative 55 islands) HPA council offices, CBO,NGO record of CBOs supporting pregnant women's nutrition interest of CBOs, women's groups; technical guidance provided 1.4 Empower mothers and caregivers, including childcare workers in state care facilities for children, to practice recommend Conduct nutrition awareness activities targeting mothers, care givers on recommended IYCF practices, appropriate food preparation and storage methods Community based BCC session designed BCC facilitators trained to deliver the sessions and piloted in 5 islands BCC facilitators trained to deliver the sessions and piloted in 10 additional islands (cumulative 15 islands) BCC facilitators trained to deliver the sessions and piloted in 10 additional islands (cumulative 25 islands) BCC facilitators trained to deliver the sessions and piloted in 10 additional islands (cumulative 35 islands) HPA ngo, mfda, women's committees island council record of sessions conducted interest of CBOs, women's groups; technical guidance provided 22 | P a g e ed IYCF practices Provide health education materials and conduct mass media campaigns to disseminate information and increase practice of recommended IYCF practices IYCF awareness info pack designed IYCF info pack Pretested and printed IYCF info pack provided to all health facilities an private clinics IYCF info pack available in health facilities IYCF info pack available in health facilities HPA media,Health facilities IYCF info pack available in health facilities resources available; Provide health education materials and conduct mass media campaigns to increase functional knowledge of mothers and care givers on nutritious food for infant feeding lEC material to increase care giver's functional knowledge about food designed and pretested IEC material published and disseminate d to health facilities and CBOs IEC materials available in health facilities and with CBOs IEC materials available in health facilities and with CBOs HPA media,Health facilities IEC materials with CBOs resources available Create a advocacy/lobby group of public health workers/ midwives and community leaders who would act as mentors and advisors to promote recommended IYCF practices in the community and household level advocacy members identified in 10 islands to promote nutrition of pregnant women advocacy members identified in 15 additional islands to promote nutrition of pregnant women (cumulative 25 islands) advocacy members identified in 15 additional islands to promote nutrition of pregnant women (cumulative 40 islands) advocacy members identified in 15 additional islands to promote nutrition of pregnant women (cumulative 55 islands) HPA HWU,MNA, MMA, NGOs health facilities record of lobby group members interest of women's groups, CBOs, community leaders, councillors 23 | P a g e Provide training to supervisors at child care facilities on recommended IYCF practices, use of BMS and growth & developmental milestones Training conducted for care workers Refresher training conducted for care workers Ministry of Gender,Fa mily and Humanrig hts HPA training records technical expertise available 1.5 Strengthen growth and developmen tal monitoring of children and referral Conduct growth and developmental monitoring monthly for all children up to at least 24 months of age in the health facilities at island level. growth and developmenta l monitoring done for all babies registered at the facility for 2yrs growth and developmenta l monitoring done for all babies registered at the facility for 2yrs growth and development al monitoring done for all babies registered at the facility for 2yrs growth and developmenta l monitoring done for all babies registered at the facility for 2yrs growth and developmenta l monitoring done for all babies registered at the facility for 2yrs Health facilities Health facilities,HPA, council offices growth monitoring records support of health service providers, mothers and care givers Ensure complete information of child's growth and development is recorded in the Child health record, both, the facility record and family record. Child health record up to date for all children registered at the health facility Child health record up to date for all children registered at the health facility Child health record up to date for all children registered at the health facility Child health record up to date for all children registered at the health facility Child health record up to date for all children registered at the health facility Health facilities health facilities/HPA growth monitoring records support of health service providers, 24 | P a g e Develop procedure for exchange of growth monitoring information from health facilities to community based public health workers SOP adopted SOP reviewed - - HPA health facilities,privat e hospitals, council offices SOP documents support of health service providers, Produce and provide child health records to health service providers - Child health records for 3 years printed Child health records available in health facilities HPA health facilities,privat e hospitals, council offices child health records in health facilities resources available Establish procedure to identify and refer children whose growth continues to falter/are becoming malnourished to provide IYCF counselling and support to their caregivers SOP adopted SOP reviewed - - HPA HPA,health facilities,counc il offices SOP documents support of health service providers, Provide refresher trainings to nurses and health care workers at health facilities on appropriate growth and developmental monitoring Refresher training provided in 3 hospitals Refresher training provided in 6 other hospitals (cumulative 9 hospitals) Refresher training provided in 6 other hospitals (cumulative 15 hospitals) Refresher training provided in 6 other hospitals (cumulative 21 hospitals) HPA health facilities,HPA training records of health corporation s, facilities support of management of health facilities; technical expertise available 25 | P a g e 1.6 Provide micronutrie nt supplement ation Provide Vitamin A supplementation through EPI and growth monitoring sessions up to 2 years through health facilities Vitamin A provided to children in all health facilities providing vaccination and growth monitoring services Vitamin A provided to children in all health facilities providing vaccination and growth monitoring services Vitamin A provided to children in all health facilities providing vaccination and growth monitoring services Vitamin A provided to children in all health facilities providing vaccination and growth monitoring services Vitamin A provided to children in all health facilities providing vaccination and growth monitoring services HPA health facilities/HPA child health records support of health service providers, care givers Provide Vitamin A supplementation through preschools up to 5 years Vitamin A provided twice a year to all children in preschools Vitamin A provided twice a year to all children in preschools Vitamin A provided twice a year to all children in preschools Vitamin A provided twice a year to all children in preschools Vitamin A provided twice a year to all children in preschools Ministry of Education MoE, HPA school event records support of school management, caregivers 26 | P a g e Revise diarrhoea treatment guidelines to include therapeutic zinc supplementation Protocol revised Protocol disseminated to all health care providers - - HPA MMA revised protocol document support of health professionals Procure annual stock of micronutrient and provide to health facilities and preschools Micronutrient s procured and sent to health facilities Micronutrient s procured and sent to health facilities Micronutrie nts procured and sent to health facilities Micronutrient s procured and sent to health facilities Micronutrient s procured and sent to health facilities HPA health facilities, schools, MoE, councils micronutrie nts available at health facilities resources available Sensitize paediatricians and GPs on the situation of micronutrient deficiencies and revised guidelines on Vitamin A and zinc supplementation Information provided to paediatricians and GPs Information provided to paediatricians and GPs HPA health facilities, HPA, MMA meeting minutes/rep ort participation and support of health professionals 27 | P a g e Create awareness of mothers on use of adequately iodized salt and appropriate storage methods group awareness session conducted in 10 islands group awareness session conducted in 15 additional islands (cumulative 25 islands) group awareness session conducted in 15 additional islands (cumulative 40 islands) group awareness session conducted in 15 additional islands (cumulative 55 islands) HPA MoE,NGOs, councils,health facilities,MFD A island council record of sessions conducted, monitoring reports support of CBOS, women's groups and island councils Conduct community/school based activities to monitor adequacy of iodine in household salt, using rapid methods iodine content monitoring conducted in 10 islands iodine content monitoring conducted in 15 additional islands (cumulative 25 islands) iodine content monitoring conducted in 15 additional islands (cumulative 40 islands) iodine content monitoring conducted in 15 additional islands (cumulative 55 islands) HPA schools, MFDA, council offices event report, monitoring reports test kits available; CBOs , schools supportive 28 | P a g e Conduct regular home visits and monitor growth monitoring and Vitamin A supplementation coverage home visits conducted in all islands home visits conducted in all islands home visits conducted in all islands home visits conducted in all islands HPA Health facilities, CBOs, NGOs Health facilities record of sessions conducted, monitoring reports support of families and island councils; trained staff available Conduct community based awareness session to increase mother's and caregiver's functional knowledge about foods rich in vitamin and minerals group awareness session conducted in 10 islands group awareness session conducted in 15 additional islands (cumulative 25 islands) group awareness session conducted in 15 additional islands (cumulative 40 islands) group awareness session conducted in 15 additional islands (cumulative 55 islands) HPA health facilities/ MoFA Health Facilities record of sessions conducted, monitoring reports support of CBOs, women groups and island councils; trained staff available 1.7 Develop nutrition programme in preschools Conduct age appropriate activities empowering children to choose healthy food BCC sessions conducted in 5 schools BCC sessions conducted in 10 additional schools (cumulative 15) BCC sessions conducted in 10 additional schools (cumulative 25) BCC sessions conducted in 10 additional schools (cumulative 35) BCC sessions conducted in 10 additional schools (cumulative 45) MoE MoE/HPA/ health facilities/ MoFA school event records trained staff/SHA available; technical support available 29 | P a g e Conduct growth monitoring of preschool children every 6 months and provide feedback to parents on the child's nutrition status Feedback of growth monitoring provided to parents in 5 schools Feedback of growth monitoring provided to parents in 10 additional schools (cumulative 15) Feedback of growth monitoring provided to parents in 10 additional schools (cumulative 25) Feedback of growth monitoring provided to parents in 10 additional schools (cumulative 35) Feedback of growth monitoring provided to parents in 10 additional schools (cumulative 45) MoE MoE/HPA/ health facilities school information system; health records of students trained staff/SHA available; technical support available Provide Vitamin A supplementation and dewormng to all children in preschools every 6 months Vitamin A & deworming provided twice a year to all children in preschools Vitamin A & deworming provided twice a year to all children in preschools Vitamin A & deworming provided twice a year to all children in preschools Vitamin A & deworming provided twice a year to all children in preschools Vitamin A & deworming provided twice a year to all children in preschools MoE MoE/HPA/ health facilities school event records trained staff/SHA available; technical support available 30 | P a g e Conduct annual analysis of nutrition of performance of the children in the preschool students nutrition status analysed in 5 schools students nutrition status analysed in 10 additional schools (cumulative 15) students nutrition status analysed in 10 additional schools (cumulative 25) students nutrition status analysed in 10 additional schools (cumulative 35) students nutrition status analysed in 10 additional schools (cumulative 45) MoE MoE/HPA/ health facilities analysis report trained staff/SHA available; technical support available Implement policy of healthy food and drinks in school for the whole school community healthy food policy implemented in 5 schools healthy food policy implemented in 10 additional schools (cumulative 15) healthy food policy implemente d in 10 additional schools (cumulative 25) healthy food policy implemented in 10 additional schools (cumulative 35) healthy food policy implemented in 10 additional schools (cumulative 45) MoE MoE/HPA/ health facilities school's healthy food policy document Parents and teachers supportive; canteen operators sensitized ACTION AREA 2: FACILITATING EASY ACCESS TO SAFE NUTRITIOUS FOOD 31 | P a g e 2.1 Develop national minimum requiremen ts of food basket and national guidelines on diet Define the national food basket as the cornerstone for developing policies and strategies for national food security Draft developed Food basket defined and adopted by NFNC - - MoED MoFT, MoFA, MoH, NCC food basket document, minutes of council meeting approving the food basket technical expertise available; policy makers supportive Develop operational plan for ensuring food security of national food basket plan developed - - MoFA MFDA/HPA/ DNP plan document technical expertise available; policy makers supportive Develop minimum nutrient content requirement for items of food basket minimum requirements defined - - HPA MCoC/MFDA minimum requiremen ts document technical expertise available; 32 | P a g e Develop national food based dietary guidelines for children and adults and sensitize food suppliers and food service providers Draft developed dietary guidelines adopted IEC materials developed to promote the guideline - HPA MED/MFDA guideline document technical expertise available; Conduct sensitization and awareness among food importers, suppliers, retailers and food service providers on national food basket and dietary guidelines - Sensitization meeting conducted - MoED chamber/ MOFA/ customs/ MFDA/ HPA meeting report participation of food importers, traders and service providers 2.2 Improve accessibility nutritious food Define maximum retail price of items of national food basket and maintain price control - MRP adopted for items of food basket - MED chamber/DNP/ MFDA/MoFA regulation notice published in gazette policy makers supportive 33 | P a g e Provide food subsidy on items of national food basket for 'poor families' under the national social protection scheme criteria and procedure for food subsidy adopted Food subsidy provision initiated - NSPA MOFA/MED/ chamber/ HPA/ ministry of gender,family and human rights subsidy criteria an notice published in gazette policy makers supportive; targeting mechanism in place Promote healthy food/fish markets supported with relevant standards and guidelines Standard on healthy fish market adopted & disseminated Standard on healthy food market adopted & disseminated - MFDA MoFA/MFDA standards document technical expertise; city/atoll councillors support Promote healthy canteens in schools, higher educational establishments and hospitals supported with relevant standards and guidelines Canteen guideline for schools drafted Canteen guideline adopted and disseminated to schools/educa tional institutions - - HPA education/healt h facillities/MF DA/NGOs canteen guideline document technical expertise; MoE policy makers & school management support 34 | P a g e Promote and support cultivation of home vegetable gardens for family consumption home gardening support provided to 10 islands home gardening support provided to additional 10 islands (cumulative 20) home gardening support provided to additional 10 islands (cumulative 30) home gardening support provided to additional 10 islands (cumulative 40) home gardening support provided to additional 10 islands (cumulative 50) MoFA MFDA/HPA/ MED MoFA monitoring records; programme records community support; island councillors support; resources available Support community based producer organizations to cultivate products of national food basket Awareness and technical support provided to CBPOs Awareness and technical support provided to CBPOs Awareness and technical support provided to CBPOs Awareness and technical support provided to CBPOs Awareness and technical support provided to CBPOs MoFA MED/chamber / HPA/MFDA/C BO MoFA monitoring records; programme records community support; island councillors support; resources available 35 | P a g e Develop SOP for providing food in emergencies, including food for infants and elderly SOP drafted SOP adopted and disseminate d to all stakeholders - NDMC MED/HPA/ MFDA/ food suppliers SOP document technical expertise available; stakeholder participation 2.3 Strengthen food quality control system Lobby support for enactment of the draft food safety law Meetings held with PO, Ag office meetings held with parliament - - MFDA parliament/PO/ MED meting minutes policy makers, law makers supportive Conduct awareness and sensitization sessions for stakeholders and consumers on aspects of food safety law - Sensitization seminar held for national agencies sensitization meeting held for atoll/councils MFDA MED, chambers, MoFA meeting minutes/rep orts participation of stakeholders; resources 36 | P a g e Develop and enforce regulations on food import, labelling, marketing and advertising of food including BMS, food production, processing, transport and storage of food products food import regulations developed labelling and marketing regulations developed food processing, transport and storage regulations developed MFDA MED, MoFA, chamber, NGOs (consumer) standards documents technical expertise available Identify and train enforcement officers up to atoll level enforcement officers provided with training on new regulations enforcement officers in Male' region provided with training on new regulations enforcement officers at atoll level provided with training on new regulations enforcement officers in Male' region provided with refresher training enforcement officers at atoll level provided with refresher training MFDA MFDA,HPA, university, Councils training records staff available; city/atoll/islan d councillor supportive Conduct post market surveillance of items of food basket linked to laboratory analysis for assessing safety and compliance with nutrient content requirements (e.g.: salt content, transfat content…) procedure for PMS developed with linkages to lab analysis PMS conducted in Male' PMS conducted for items of food basket in 4 atolls PMS conducted for items of food basket in 4 other atolls (cumulative 8) PMS conducted for items of food basket in 4 other atolls (cumulative 12) MFDA MED/HPA PMS records technical staff available; resources for laboratory functioning available 37 | P a g e Maintain ISO accreditation status of microbiology and chemistry lab of National Health Laboratory consumables procurement plan and equipment maintenance plan developed renew accreditation status of microbiology lab calibration audit conducted renew accreditation status of chemistry lab caliberation audit conducted MFDA MoH,MoFA, MoED audit and assessment reports technical expertise available; resources available Develop laboratory capacity to undertake nutrient content, pesticides and heavy metals analysis of food products, capacity for micronutrient analysis developed capacity for heavy metal analysis developed capacity for pesticide analysis developed MFDA HPA analysis reports and lab data resources available; trained staff in place 2.4 Develop an integrated food borne disease surveillance system Develop case definition and reporting protocols for food borne and food based diseases case definitions and protocol developed SIDAS modified to integrate FBD surveillance - - HPA MFDA/health facillities case definition documents technical expertise available; health facillities Conduct TOT for health care providers on diseases and reporting mechanism for food borne disease surveillance TOT conducted for focal points of health service corporations - - HPA MFDA/disaste r management/ health facillities training records staff available for training 38 | P a g e Provide training to doctors on diseases and reporting mechanism for food borne disease surveillance Training conducted in for facilities in 4 health service corporations Training conducted in for facilities in 4 other health service corporations - HPA health facillities training records staff available for training Identify roles and responsibilities of health care providers, public health officers and food safety enforcement officers and key agencies in food borne surveillance and outbreak control SOP for case investigation and outbreak control for FBD developed stakeholder agencies oriented to the SOP refresher training provided to stakeholders on SOP HPA MFDA/MoFA/ health facillities SOP document; roles and responsibili ties known to institutions/ staff good coordination between stakeholders Develop SOPs for risk assessment, risk communication and management related to food borne diseases and food based health hazards SOP for risk assessment, communicati on and mgmt developed stakeholder agencies oriented to the SOP refresher training provided to stakeholders on SOP MFDA HPA/MoFA/ health facillities SOP document; roles and responsibili ties known to institutions/ staff good coordination between stakeholders ACTION AREA 3: PROVIDE INFORMATION AND COMMUNICATION FOR BEHAVIOUR CHANGE 39 | P a g e 3.1 According priority to nutrition in development Conduct analysis of estimated economic impact of current nutrition status and cost/benefit of implementing the proposed nutrition interventions in this plan cost benefit analysis done - - - Maldives National University MoH/ HPA analysis report technical expertise available Conduct forum for policy makers to disseminate findings of the economic analysis Disseminatio n meeting held - - MoH MNU report of meeting interest and participation of policy makers Prepare projects to obtain external support to improve nutrition status of population in regions that lag behind national average 2 projects developed 2 projects developed HPA MFDA/ MoFA/ UNICEF/ WHO/ FAO project documents technical expertise available 3.2 Provide nutrition information and education through audiovisual and print media Develop mass media campaigns to improve situation of IYCF practices, micronutrient deficiencies and obesity campaign on IYCF conducted campaign on MN deficiencies conducted Campaign on obesity conducted HPA MFDA/ MoFA/all councils/ Health facilities media materials; broadcast times resources available; media partnership under CSR 40 | P a g e Produce IEC materials to support dissemination of nutrition information through health care facilities and schools to specific target groups IEC material on IYCF developed IEC material on MN developed IEC material on obesity developed HPA MoE/ schools/ health facillities IEC materials in schools and health facilities resources available; health service providers and school management supportive Utilize popular local websites and internet social networking tools to disseminate healthy food selection and dietary practices to adolescents and young people messages uploaded on popular local websites messages uploaded on popular local websites messages uploaded on popular local websites messages uploaded on popular local websites HPA internet service providers; popular websites nutrition messages displayed on websites website owners support 3.3 Strengthen behaviour change interventions Conduct positive deviance programmes in island/atolls with poor nutrition status of children PD implemented in 10 islands PD implemented in 10 additional islands (cumulative 20) PD implemente d in 10 additional islands (cumulative 30) PD implemented in 10 additional islands (cumulative 40) PD implemented in 10 additional islands (cumulative 50) HPA UNICEF monitoring reports; island council records technical staff in place; councillors support; women's groups support Develop target group specific BCC interventions targeting overweight and obese adults 20 group education sessions conducted 30 additional group education sessions conducted (cumulative 50) 20 additional group education sessions conducted (cumulative 70) 30 additional group education sessions conducted (cumulative 100) 30 additional group education sessions conducted (cumulative 130) HPA MFDA, MoE. Youth and Sports, All councils, fitness clubs, ngos monitoring reports; island council records technical staff in place; councillors support; women's groups & CBOs support 41 | P a g e Develop skill based education programmes targeting women in food selection and healthy food preparation 10 group education sessions conducted 10 additional group education sessions conducted (cumulative 20) 10 additional group education sessions conducted (cumulative 30) 10 additional group education sessions conducted (cumulative 40) 10 additional group education sessions conducted (cumulative 50) HPA MFDA, health facilities, women's committees, ngos monitoring reports; island council records technical staff in place; councillors support; women's groups & CBOs support 3.4 Develop healthy dietary practices in students and young people Develop skill based nutrition education modules targeting key stages of learning aligned to national curriculum nutrition education modules developed and piloted - - MOE HPA/ MNU curriculum and modules technical expertise available Train peer educators in schools and conduct peer education interventions at school level 15 peer educators trained in Male' 15 peer educators trained in 5 atolls each 15 peer educators trained in 7 atolls each 15 peer educators trained in 7 atolls each MOE HPA/ MNU training records of school health programme , MOE technical expertise and resources available Train school health assistants to conduct school based nutrition education interventions targeting whole school community Training given to SHA in Male' schools Training given to SHA in 5 atoll schools Training given to SHA in 7 atoll schools Training given to SHA in 7 atoll schools MOE MNU(FHS), CCE training records of school health programme , MOE technical expertise and resources available 42 | P a g e Provide training to primary and secondary teachers to deliver skill based nutrition education through curriculum through teacher training courses at Faculty of education modules for teacher training developed nutrition education included in primary teacher training course at FE nutrition education included in secondary teacher training course at FE MOE MNU(FoE), HPA curriculum and modules eligible candidates and lecturers available Engage parents and students in provision of healthy meals and snack in school functions and fairs information session conducted for patents in 5 schools information session conducted for patents in 10addiitonal schools (cumulative 15 schools) information session conducted for patents in 10addiitonal schools (cumulative 25 schools) information session conducted for patents in 10addiitonal schools (cumulative 35 schools) information session conducted for patents in 10addiitonal schools (cumulative 45 schools) Schools MoE/private food service providers school records of events parents and teachers aware and supportive 3.5 Inform food producers, traders and service providers on the food and nutrition requirement of the population Conduct awareness session for food importers and traders on the need to make available healthier food products one information session conducted for importers and traders one information session conducted for importers and traders one information session conducted for importers and traders one information session conducted for importers and traders one information session conducted for importers and traders MFDA MED, Customs, Maldives chamber of commerce,MP L, HPA meeting records participation of traders, importers 43 | P a g e Provide simple guidelines and reminders on appropriate storage, transport and handling of food and food products guidelines on handling storage and transport of health sensible food developed guidelines on handling storage and transport of perishable items developed IEC material on the guidelines developed and disseminated to traders MFDA MED, Customs, Maldives chamber of commerce/MP L/transport authority standard and guideline documents technical expertise available Educate agricultural land owners/workers and community based producer organization on appropriate use of fertilizers and pesticides Training provided to CBPOs and agri workers in 5 islands Training provided to CBPOs and agri workers in 10 islands (cumulative 15) Training provided to CBPOs and agri workers in 10 islands (cumulative 25) Training provided to CBPOs and agri workers in 10 islands (cumulative 35) Training provided to CBPOs and agri workers in 10 islands (cumulative 45) MoFA MFDA, HPA training records and monitoring reports technical staff available ACTION AREA 4: FACILITATING NATIONAL COORDINATION 4.1 Supporting national food and nutrition council Develop relevant policy briefs for evidence based decision making in the council policy brief on food basket developed policy brief on BMS code developed policy brief on role of nutrition in national development developed policy brief on price control of food basket developed MoH Economic Development, Customs,Presi dent Office,MoFA policy brief documents technical expertise available Ensure regular participation of key sectors in the council and its task group meetings all stakeholders participate in meetings of council and task groups all stakeholders participate in meetings of council and task groups all stakeholders participate in meetings of council and task groups all stakeholders participate in meetings of council and task groups all stakeholders participate in meetings of council and task groups PO stakeholders agencies of the council meeting minutes interest at policy making level 44 | P a g e Develop procedure to disseminate decisions of the council across sectors and within sectoral institutions rules of procedure for the council and task groups adopted - - - PO/Counc il secretariat stakeholders agencies of the council ROP document support from council members for clear and transparent mechanism 4.2 Strengthen coordinatio n of nutrition services within the health system Define the nutrition services to be delivered at health facilities, together with requirements of records keeping, reporting services and requirements defined defined services and requirements reviewed and improved - - MoH All health facilities official document defining services from MoH and Health Facilities policy support for clear and transparent mechanisms Define the nutrition services to be delivered by community based public health workers with requirements of record keeping and reporting services and requirements defined defined services and requirements reviewed and improved - - MoH/HP A Health units at island level official document defining services from MoH and Facilities policy support for clear and transparent mechanisms Develop reporting and referral protocol between health service providers and community based public health workers protocol developed and disseminated protocol reviewed and improved - - MoH Health facillities protocol document policy support for clear and transparent mechanisms Develop procedures for communication and coordination between national nutrition programme and atoll/city SOP developed SOP reviewed and improved - - MoH/HP A MoH/Councils SOP document policy support for clear and transparent mechanisms 45 | P a g e councils' health personnel and health service providers in the health facilities Develop procedure for communication and support to school health nutrition services from national public health institutions SOP developed SOP reviewed and improved - - MoE HPA SOP document policy support for clear and transparent mechanisms Develop procedure for supply of essential nutrition commodities such as vitamin supplements, to be delivered, stored and stock maintained at health faculties in collaboration with the health service providers SOP developed SOP reviewed and improved - - MoH/HP A All health facilities SOP document policy support for clear and transparent mechanisms Develop guideline on nutrition interventions and advice that must be provided at ANC and PNC clinics or OP consultations and conduct TOT guideline developed and TOT conducted in Male' TOT conducted for 4 health corporations TOT conducted for 4 health corporations HPA health professional's associations, Health Facilities guideline document and training records at HPA technical expertise and resources available 46 | P a g e Provide training to nurses on delivering these information and interventions nurses in health facilities in Male' region trained nurses in health facilities in 4 corporations trained nurses in health facilities in 4 corporations trained Health Facillities HPA, Maldives nurses association training records at Health facilities priority given by management of health facilities Develop nutrition guidelines on enteral and parentral feeding for bedridden patients and train nurses on the guideline guideline developed and TOT conducted for focal points from all health corporations - - HPA Health Facillities, health professionals' associations guideline document and training records at HPA technical expertise and resources available Conduct forum of health service providers, atoll/city councils and national nutrition programme to discuss situation, issues of implementation and coordination forum held - forum held - MoH/HP A Health Facillities and All Councils training records at health facilities priority given by management of health facilities Conduct home visits by community based public health workers to monitor nutrition status of children under 5 and pregnant mothers s well as coverage of growth monitoring, vitamin supplementation home visits conducted in all islands home visits conducted in all islands home visits conducted in all islands home visits conducted in all islands home visits conducted in all islands MoH/HP A Health facillities at island level records of home visits at island councils priority given by island councils 47 | P a g e Provide support to community based organizations and women's group to implement nutrition related peer education programmes and positive deviance programmes CBOs supported in 10 islands CBOs supported in 10 additional islands (cumulative 20) CBOs supported in 10 additional islands (cumulative 30) CBOs supported in 10 additional islands (cumulative 40) MoH/HP A All health facillities at island level reports of activities supported by HPA/MoH CBOs interest in nutrition promotion Develop procedure for monitoring of nutrition programmes and services at health faculties monitoring tools and procedure developed and adopted monitoring conducted in 5 atolls monitoring conducted in 3 atolls & in Male region monitoring conducted in 6 atolls monitoring conducted in 6 atolls MoH/HP A Health facillities/Cou ncils monitoring reports technical staff and resources available 4.3 Facilitate atoll/city level planning of nutrition of nutrition programme s Provide guidance and support to atoll/city councils to develop nutrition projects and interventions as part of their development projects and plans support provided support provided support provided support provided support provided MoH/HP A HPA/MFDA/ MoFA/island Councils reports of activities supported by HPA/MoH Councillors interest in nutrition promotion Support implementation of selective nutrition interventions based on local nutrition situation support provided support provided support provided support provided support provided MoH/HP A HPA/MFDA/ MoFA/island Councils reports of activities supported by HPA/MoH Councillors interest in nutrition promotion 48 | P a g e Conduct city/atoll level nutrition problem solving workshops involving community groups and decision makers workshop held in 6atolls workshop held in 4 other atolls workshop held in 6 other atolls workshop held in 4 other atolls City/Atoll Councils HPA/MFDA/ MoFA/island Councils workshop reports Councillors interest in nutrition promotion; technical expertise available Support use of city/atoll level information for project planning purposes information analysed at city/ atoll level information analysed at city/ atoll level information analysed at city/ atoll level information analysed at city/ atoll level information analysed at city/ atoll level City/Atoll Councils Councils city/atoll level analysis reports/stati stics technical staff available at city/atoll level 4.4 Develop technical capacity for nutrition services Identify local candidates that could be trained in nutrition who would work at island level with support of island councils candidates identified candidates identified candidates who are financed by the councils bonded to serve the atoll Island Council ,Atoll Council, Health facillities, HPA, MFDA, MoFA city/atoll/is land council records of list of bonded candidates under training eligible candidate available; priority accorded to training in food and nutrition by the city/atoll councils Develop projects for fund mobilization to support training of candidates who are willing to work at atoll and island levels project developed - - Atoll/Loc al Councils Atoll Council/HPA/ MFDA/MoFA project document nutrition prioritised for development Conduct short course on nutrition through FHS short course on nutrition announced 10 candidates trained 20 candidates trained (cumulative 30) 20 candidates trained (cumulative 50) 20 candidates trained (cumulative 70) MNU/FH S HPA, MFDA,Counci ls course announcem ent; list of trained candidates eligible candidate available; lectureres available 49 | P a g e Provide training to community based public health workers on nutrition and food safety enforcement functions training session conducted in Male' region training session conducted in 6 atolls training session conducted in 4 other atolls training session conducted in 6 other atolls training session conducted in 4 other atolls HPA/MF DA MoED,MOFA, local councils training records at HPA/ MFDA and city/atoll councils technical expertise and resources available; staff in place Provide training to community based public health workers on health/nutrition promotion and BCC training session conducted in Male' region training session conducted in 6 atolls training session conducted in 4 atolls training session conducted in 6 atolls training session conducted in 4 atolls HPA MFDA,Health Facillities,islan d councils training records at HPA/ MFDA and city/atoll councils technical expertise and resources available; staff in place Explore opportunity to increase number of staff trained in food and nutrition up to postgraduate level at central and atoll/city levels scholarship opportunity provided for 1 candidate scholarship opportunity provided for 1 candidate scholarship opportunity provided for 1 candidate scholarship opportunity provided for 1 candidate MoH stakeholders of the food and nutrition council, Dept of higher education, MNU training records of dept of higher education/ MoH/ MOFA eligible candidates available; resources available; food and nutrition accorded priority for higher education ACTION AREA 5: SUPPORTING POLICY WITH INFORMATION AND RESEARCH 5.1 Conduct primary and secondary research in priority areas of food and nutrition Conduct a population based food consumption study food consumption study conducted - - MNU HPA, MFDA, MoFA,UN technical agencies study protocol, study report technical expertise and resources available Conduct a total dietary study - TDS conducted - MNU MFDA, HPA, MoFA,UN technical study protocol, study report technical expertise and resources available 50 | P a g e agencies Undertake analysis of existing data sets to determine disparity in nutrition due to socioeconomic status disparity analysis conducted - - DNP MoH, HPA analysis report technical expertise available Undertake analysis of students' height and weight data to determine prevalence of undernutrtion and obesity among students in primary and secondary schools students ht/wt data analysed - - - MoE Schools, HPA analysis report data readily available Conduct assessment of growth monitoring coverage coverage assessed - - HPA Health facilities report of assessment technical expertise and resources available Conduct functional analysis of health care workers engaged in nutrition services in health facilities - - functional analysis conducted MNU Health facillities, HPA, MFDA analysis report technical capacity and resources available Conduct hospital based research to estimate the prevalence of food borne/based diseases FBD prevalence study conducted - - MNU HPA, Health facillities, local Councils, MFDA study report medical records available; technical expertise available 51 | P a g e Conduct study on effectiveness of the community based BCC interventions - - BCC interventions assessed MNU HPA/ Health Facilities NGOs report of assessment technical expertise and resources available 5.2 Strengthen food and nutrition data collection, analysis and disseminati on Develop the child health and nutrition surveillance system, with SOPs for data flow and feedback System launched system reviewed - - MoH/HP A UNICEF, WHO reports generated from the system technical expertise and resources available Produce annual report of growth monitoring coverage and child nutrition status disaggregated by gender and atolls/cities and provide data for publication in statistical year book annual data on nutrition status produced and provided to DNP nutrition data published in statistical year book nutrition data published in statistical year book nutrition data published in statistical year book nutrition data published in statistical year book HPA DNP, Health facilities, island councils published data in statistical year book routine data maintained Produce information dataset on import and post market surveillance information annually, covering compliance with food safety and nutrition requirements and provide data for publication in statistical year book annual data on food safety produced and provided to DNP food safety data published in statistical year book food safety data published in statistical year book food safety data published in statistical year book food safety data published in statistical year book MFDA MoED, Customs Services, DNP published data in statistical year book routine data maintained Integrate food borne disease surveillance with SIDAS - FBD integrated into SIDAS - HPA MFDA, Health facilities reports generated from SIDAS technical expertise available 52 | P a g e Establish linkages with food availability data collection mechanism and nutrition information linkages identified nutrition status analyzed in the context of food security nutrition status analyzed in the context of food security DNP HPA, MOFA, MoED, councils cross linked data good coordination exist between agencies Publish food availability information in statistical year book annual data on food availability in all atolls produced and provided to DNP food availability data covering all atolls published in statistical year book food availability data covering all atolls published in statistical year book food availability data covering all atolls published in statistical year book food availability data covering all atolls published in statistical year book DNP MoFA,MFDA, Maldives Customs Service, city/atoll councils published data in statistical year book routine data maintained 5.3 Establish monitoring and evaluation mechanism Develop methodology and tools for monitoring of nutrition services and interventions at health facilities and in community methodology for monitoring defined and adopted methodology reviewed and improved - - MoH/HP A Local Councils, Health Facilities monitoring methodolo gy document technical expertise available Develop procedure to undertake regular monitoring of nutrition services and interventions at health facilities and in community, with clear roles and responsibilities of institutions involved procedure developed and adopted procedure reviewed and improved - - MoH/HP A Local Councils, Health Facilities SOP document technical expertise available Conduct annual monitoring visits from national nutrition and food safety programme to monitoring conducted in 5 atolls monitoring conducted in 3 atolls & in Male region monitoring conducted in 6 atolls monitoring conducted in 6 atolls HPA/MF DA MoFA,Local Councils, Health Facilities monitoring reports resources available 53 | P a g e selected locations Provide feedback to health service providers and island councils on finding of monitoring feedback meeting held with councillors and health service providers feedback meeting held with councillors and health service providers feedback meeting held with councillors and health service providers feedback meeting held with councillors and health service providers HPA/MF DA MoFA, Local Councils, Health Facilities feedback meetings minutes interest at decision making levels Develop Monitoring and evaluation plan for this action plan M&E plan developed - - - HPA Stakeholders of Food and nutrition council M&E plan document technical expertise available Conduct review and evaluation of national food and nutrition framework 3 years of implementation - - review conducted and feedback provided to food and nutrition council MoH Atoll/City/Isla nd councils, Health Facilities, Stakeholders of Food and nutrition council review report technical expertise and resources available Disseminate widely the findings of evaluation and programme review - - Disseminatio n meeting held in Male' region and 2 other regions Disseminatio n meeting held in 5 other regions MoH Health Facilities, Stakeholders of Food and nutrition, councilAtoll/C ity/Island councils, report of disseminati on meetings technical expertise and resources available; interest at policy making level 54 | P a g e ACTION AREA 6: ADDRESSING DETERMINANTS OF NUTRITION 6.1 Promote physical activity through life course Develop teaching modules on physical activity for key learning stages aligned to the national curriculum teaching modules developed and piloted - - EDC FE (MNU) MoHRYS, MoH modules; EDC administrat ive records new curriculum endorsed; technical capacity available, Provide opportunity for physical activity and sports through regular school sessions for secondary school students physical activity classes held during school session in 2 secondary schools physical activity classes held during school session in 3 other secondary schools (cumulative 5) physical activity classes held during school session in 5 other secondary schools (cumulative 10) physical activity classes held during school session in 5 other secondary schools (cumulative 15) physical activity classes held during school session in 5 other secondary schools (cumulative 20) MoE MoE,MoHRY S, island councils School time tables single school sessions policy implemented; parents support Train primary and secondary teachers on delivering the modules on physical education with support of Faculty of Education curriculum and modules for teacher training developed physical education included in primary teacher training course at FE physical education teacher training course conducted at FE MoE Maldives National University and MoHRYS curriculum; modules; FE administrat ive records new curriculum endorsed; technical capacity available, Support women's groups in islands to conduct physical activity programmes for women of reproductive age women's groups supported women's groups supported women's groups supported women's groups supported women's groups supported Atoll/City Council HPA/ MoHRYS/ Local Council Council office administrat ive records women's groups active 55 | P a g e Encourage weekly sports events at island level for young people and adults weekly sports events in 10 islands weekly sports events in 10 other islands (cumulative 20) weekly sports events in 10 other islands (cumulative 30) weekly sports events in 10 other islands (cumulative 40) weekly sports events in 10 other islands (cumulative 50) Atoll/City Council NGOs Council office administrat ive records CBOs active; councillors support Encourage wider use of sports grounds, beach and sea for physical activity sports grounds used for physical activity other than sports in 10 islands sports grounds used for physical activity other than sports in 10 other islands (cumulative 20) sports grounds used for physical activity other than sports in 10 other islands (cumulative 30) sports grounds used for physical activity other than sports in 10 other islands (cumulative 40) sports grounds used for physical activity other than sports in 10 other islands (cumulative 50) Atoll/City Council MoHRYS, NGOs Council office administrat ive records CBOs active; councillors support 6.2 Improve hygiene behaviour among children and young people Encourage children and caregivers to wash hands with soap and water before eating, feeding and food preparation hand washing messages provided during home visits hand washing messages provided during home visits hand washing messages provided during home visits hand washing messages provided during home visits hand washing messages provided during home visits island councils HPA/ MoE/MFDA Council office records of home visits Health care providers support Provide soap and water or antiseptic hand wash in toilets of schools, child care facilities, health facilities and public places all schools and health facilities have soap in toilets all schools and health facilities have soap in toilets all schools and health facilities have soap in toilets all schools and health facilities have soap in toilets all schools and health facilities have soap in toilets Schools, health facilities, public services MoE, Health facilities, local councils, school administrat ive records, stock records school management support; manageable resources 56 | P a g e Disseminate hygiene and hand washing messages through mass media and IEC materials hand washing messages disseminated through mass media hand washing messages disseminated through mass media hand washing messages disseminate d through mass media hand washing messages disseminated through mass media hand washing messages disseminated through mass media HPA MEDIA broadcast records support of mass media institutions 6.3 Support girls education beyond primary education Provide opportunities for secondary education through distance learning Distance learning opportunity made available - - CCE MoE, MoHRYS, MNU CCE administrat ive records technical and technological capacity available; community support Provide hostel facilities for girls in islands with secondary and higher education hostels for secondary students established at atoll level in 2 atolls hostels for secondary students established at atoll level in 2 other atolls (cumulative 4) hostels for secondary students established at atoll level in 2 other atolls (cumulative 6) hostels for secondary students established at atoll level in 2 other atolls (cumulative 8) hostels for secondary students established at atoll level in 2 other atolls (cumulative 10 ) MoE Atoll/city council project records recognized as a priority by councillors, government; adequate resources available Provide free/subsidized transport services for girls to attend secondary schools in other nearby islands criteria for transport subsidy provision adopted transport subsidy provided for girls transport subsidy provided for girls transport subsidy provided for girls transport subsidy provided for girls MoE MoTC, Local Councils, transport providers NSPA criteria for subsidy; administrat ive records recognized as a priority by government; 57 | P a g e Annex II: References 1. National Nutrition Strategic Plan 2008-2010 Department of Public Health, Male, Republic of Maldives. 2. Maldives Demographic Health Survey 2009, Ministry of Health, Male’ , Republic of Maldives 3. National Micronutrient Survey 2007, Ministry of Health, Male’, Republic of Maldives 4. National Food and nutrition Framework, Draft, Unpublished, 2011, Health Protection Agency 5. Nutrition Situation assessment Report, Draft, Unpublished, 2010, Health Protection Agency 6. Multiple Indicator Cluster Survey 2001, UNICEF Maldives Country Office, Male’ 7. Ministry of Education, CDC and WHO 2010; 2009 Maldives Global Student-based School Health Survey, GSHS Country Report; Ministry of Education, Male’ 8. Health Statistics, 2009; Ministry of Health, Male’ 9. WHO regional Nutrition Strategy : Addressing Malnutrition and micronutrient deficiencies (2011-2015), WHO, Regional Office For South Asia 58 | P a g e Annex III: List of Acronyms ANC BCC BFHI BMS BMI CBO CSC DNP EBF FAO FHS FNC FoE GSHS HPA HWU HRC IEC ICN INNSP IYCF MDHS MICS MNS MoE MoHRYS MFDA MoFA MoED MoH MNU MNA MMA Antenatal Care Behaviour Change Communication Baby Friendly Hospital Initiative Breast Milk Substitute Body Mass Index Community Based Organization Civil Service Commission Department of National Registration Exclusive Breastfeeding Food and Agriculture Organization Faculty of Health sciences Food and Nutrition Council Faculty of Education Global School Health Survey Health Protection Agency Health workers Union Human Rights Commission Information, Education and Communication International Conference on Nutrition Integrated National Nutrition Strategic Plan Infant and Young Child Feeding Maldives Demographic and Health Survey Multiple Cluster Indicator Survey Micronutrient Survey Ministry of Education Ministry of Human Resource Youth and Sports Maldives Food and Drug Authority Ministry of Fisheries and Agriculture Ministry of Economic Development Ministry of Health Maldives National University Maldives Nurses Association Maldives Medical association 59 | P a g e NNS NNP NNSP NGO PO PHC PNC SES SOP SIDAS ROP TDS TOT WHO UN National Nutrition Strategy National Nutrition plan National Nutrition Strategic Plan Non-governmental Organization President Office Primary Health Care Postnatal Care Socio Economic Status Standard Operating Procedure SEARO Integrated Data Analysis System Rules of Procedure Total dietary Survey Training of Trainers World Health Organization United Nation