Multi-sector Strategic Plan to reduce Malnutrition in Sierra Leone (2019-2025)

1 | P a g e I. Table of contents I. Table of contents ........................................................................................................................................ 1 II. List of Acronyms ......................................................................................................................................... 2 III. Forward…. ................................................................................................................................................ 5 IV. Acknowledgements ................................................................................................................................... 6 V. Executive Summary ................................................................................................................................... 7 VI. Introduction .............................................................................................................................................. 8 VII. Review Methodology ................................................................................................................................ 9 VIII. Situation Analysis................................................................................................................................... 11 A. Country Situation Overview .................................................................................................................. 11 B. Nutrition Conceptual Framework .......................................................................................................... 12 C. Policy Overview ..................................................................................................................................... 14 D. Multi-Sectoral Nutrition Situation Analysis ........................................................................................... 16 IX. Lessons Learned, Challenges & Opportunities ...................................................................................... 24 X. Strategic Priorities ................................................................................................................................... 26 A. Key Target Populations .......................................................................................................................... 26 B. Goal ........................................................................................................................................................ 26 C. Objectives .............................................................................................................................................. 27 D. Strategic Directions & Priority Activities ............................................................................................... 28 XI. Results, M & E Framework .................................................................................................................... 34 XII. Risks Mitigation Framework .................................................................................................................. 38 XIII. Summary Budget by Objective .............................................................................................................. 42 XIV. Annexes ................................................................................................................................................. 43 2 | P a g e II. List of Acronyms 6MCP 6 Month Contact Point 6MlyCP 6 Monthly Contact Point ABC Agricultural Business Centre AfDB African Development Bank AHS African Health Strategy (African Union Commission) AIDS Acquired Immune Deficiency Syndrome APRM Annual Peer Review Mechanism ARNS Africa Regional Nutrition Strategy (African Union Commission) BFHI Baby Friendly Hospital Initiative BMI Body Mass Index BEmONC Basic Emergency Obstetric and Neonatal Care CAADP Comprehensive Africa Agriculture Development Programme CFSVA Comprehensive Food Security Vulnerability Assessment CFW Cash for Work CHWS Community Health Workers CMAM Community Management of Acute Malnutrition CSE Comprehensive Sexual Education DHMT District Health Management Team DHS Demographic Health Survey DOP District Operational Plan ECOWAS Economic Community of West African States EPI Expanded Programme on Immunisation EWS Early Warning Systems FAO Food and Agricultural Organization of the United Nations FBOs Farmer-Based Organisations DFN Directorate of Food and Nutrition, Ministry of Health and Sanitation FFS Farmer Field Schools FFW Food for Work FHCI Free Health Care Initiative FP Family Planning GAM Global Acute Malnutrition GoSL Government of Sierra Leone HIV Human Immuno-deficiency Virus IAP Independent Accountability Panel IEC Information, Education and Communication IDPs Internally displaced persons IFAD International Fund for Agricultural Development IMAM Integrated Management of Acute Malnutrition IPTp Intermittent Preventive Treatment in pregnancy IPTi Intermittent Preventive Treatment in infancy ITN Insecticide Treated Nets ITP Inpatient Therapeutic Programme IYCF Infant and Young Child Feeding IVS Inland Valley Swamps LARC Long-Acting Reversible Contraception MAFFS Ministry of Agriculture, Forestry and Food Security MAM Moderate Acute Malnutrition mCPR Contraceptive Prevalence Rate by modern methods MDGs Millennium Development Goals MEST Ministry of Education, Science and Technology MEWR Ministry of Energy and Water Resources MICS Multiple Indicator Cluster Survey 3 | P a g e MFMR Ministry of Fisheries and Marine Resources MOFED Ministry of Finance and Economic Development MOHS Ministry of Health and Sanitation MBSSE Ministry of Basic and Senior Secondary Education MoTHE Ministry of Technical and Higher Education MNP Micro Nutrient Powder MSG Mother Support Group MSWGCA Ministry of Social Welfare, Gender and Children’s Affairs MTI Ministry of Trade and Industry MUAC Mid-Upper Arm Circumference NCDs Non-Communicable Diseases NFNSIP National Food and Nutrition Security Strategic Implementation Plan NGO Non-Governmental Organisation NTD/NTDs Neglected Tropical Disease/Diseases ODF Open Defecation Free OI Output Indicators ONS Office of National Security ORS Oral Rehydration Salts ORT Oral Rehydration Therapy OTP Outpatient Therapeutic Programme OVC Orphans and Vulnerable Children OVP Office of the Vice-President of Sierra Leone P4P Purchase for Progress PHU Peripheral Health Unit PLHIV/TB People Living with HIV and AIDS or Tuberculosis PLW Pregnant and Lactating Women PMTCT Prevention of Mother to Child Transmission PMNCH Partnership for Maternal, Neonatal & Child Health PTAG Presidential Taskforce on Agriculture POP/FLE Population and Family Life Education REACH Renewed Efforts Against Child Hunger and Under-nutrition RCH Reproductive and Child Health RHFP Reproductive Health and Family Planning RM Road Map RMEF Results Monitoring and Evaluation Framework RMNCAH Reproductive, Maternal, New born, Child and Adolescent Health SAM Severe Acute Malnutrition SBCC Social Behaviour Change Communication SCP Smallholder Commercialisation Programme SDGs Sustainable Development Goals SFP Supplementary Feeding Programme SLARI Sierra Leone Agricultural Research Institute SLDHBS Sierra Leone District Health Baseline Survey SMART Standardised Monitoring and Assessment of Relief and Transitions SMC School Management Committee SMS Short Messaging Service SNAP Sustainable Nutrition and Agriculture Programme SSHE School Sanitation and Hygiene Education STH Soil Transmitted Helminths SUN Scaling Up Nutrition TB Tuberculosis TOR Terms of Reference TWG Technical Working Group UN United Nations 4 | P a g e UNFPA United Nations Population Fund UNICEF United Nations Children Fund UNN UN Network VAD Vitamin A deficiency VAS Vitamin A Supplementation VHC Village Health Committees WB World Bank WFP World Food Programme of the United Nations WHO World Health Organisation 5 | P a g e III. Foreword 6 | P a g e IV. Acknowledgements Under the overall guidance of the Scaling Up Nutrition Secretariat in the Office of the Vice President of Sierra Leone and the technical guidance by the Technical Working Group (TWG) created for this exercise, the REACH (Renewed Efforts Against Child Hunger and Undernutrition) through the United Nations Network (UNN) recruited an international consultant who conducted extensive desk reviews and consultations with Government, Civil Society, the Private Sector, some United Nations Agencies and other Development Partners in Sierra Leone in order to produce this document. The review, consultation, analysis and drafting were performed by the UNN REACH Senior International Consultant, Dr. Akram Ali Eltoum Mohamed, between November 2017 and August 2018. The Government of Sierra Leone wishes to express its sincere appreciation for the proactive participation, thoughtful technical and editorial contributions to this exercise from all national and international stakeholders who were consulted throughout this process at both national and district levels in Sierra Leone. Special gratitude must be expressed for the strong leadership and coordination provided by the UNN Chair, the UNICEF Country Representative (Dr. Hamid El-Bashir) and the REACH, National Facilitator (Dr. Philip John Kanu) as well as the UNN Focal Points (particularly FAO, UNICEF, WFP and WHO). Similar gratitude must also be expressed to all the Members of the Technical Working Group (TWG) and international non-governmental organizations such as Hellen Keller International, Action Against Hunger and FOCUS 1000, the Chair for Civil Society Organizations (CSOs) in Sierra Leone. The review and consultation effort as well as the production of this document could not have been possible without the generous coordination, technical and financial support of the Government of Ireland’s Irish Aid (Donor Convener). Other donors whose contributions to the consultative process remains very highly appreciated include USAID (United States Agency for International Development), AfDB (African Development Bank), EU (European Union) and WB (World Bank Group). Last, but certainly not least, deepest gratitude is owed to the front-line change agents among the adolescents, mothers, community leaders, multi-sectoral government and civil society workers in all the villages, wards, chiefdoms and districts of Sierra Leone. As the ultimate stakeholders and change agents seeking better nutrition, these groups are bravely addressing the challenges of nutrition and food security head-on and daily throughout Sierra Leone. It is they who will require the strongest support to achieve their goals of service to their citizens. It is their toil that sows the seeds of better nutrition and health so that Sierra Leoneans can transform their country. 7 | P a g e V. Executive Summary Sierra Leone had implemented its first National Food and Nutrition Strategic Implementation Plan (NFNSIP) between 2013 and 2017, under the leadership of the Scaling Up Nutrition (SUN) Secretariat hosted in the Office of the Vice-President. Considerable support from the United Nations (UN), donors and international non-governmental organizations enabled the achievement of the modest progress towards the NFNSIP 2013-2017 targets, while several factors have impeded more progress. The review process undertaken since November 2017 by Renewed Efforts Against Child Hunger and Undernutrition (REACH) and United Nations Network (UNN) in support of the SUN Secretariat highlighted numerous challenges which resulted in this mixed picture. Chief among them are the weak nutrition governance structures, under-resourced management, and implementation efforts as well as the Ebola outbreak. In response to these challenges and with the aim of drastically reducing malnutrition in Sierra Leone, the Government of Sierra Leone through the SUN Secretariat requested the support of REACH through the UNN to review the progress achieved, analyzing the challenges and documenting the lessons learned as well as the opportunities for a new strategy to cover the period 2019-2025. This document reflects that effort and is a culmination of extensive literature reviews, stakeholder consultations and field visits across the country. The analysis considered past achievements and future directions in the context of the conceptual framework for nutrition security adopted globally and, in many countries, faced with similar challenges as Sierra Leone. The conceptual framework consists of three pillars comprising nutrition-specific, nutrition-sensitive and enabling environment interventions. The greatest burden of nutrition-related disease appears to fall on rural populations, particularly rural women, with pockets of deep poverty and lack of access to nutrition and health services seen also among the urban poor, in specific highly-vulnerable populations such as people living with chronic diseases, people with special needs, orphans, children and adolescents. Among others identified in the analysis, the neglect of certain needed interventions within the three pillars, insufficient empowerment of subnational levels of governance as well as inequitable investments across districts, population segments and intervention types were all identified as key gaps. Accordingly, the goal of the new multi-sector strategy to reduce malnutrition in Sierra Leone is to contribute to the African Union’s Africa Regional Nutrition Strategy (2015-2025), the UN Sustainable Development Goals by 2030 and the UN Global Strategy for Maternal, Newborn, Child and Adolescent Health (2016-2030) by accelerating and scaling-up nutrition action across all sectors in Sierra Leone. Specifically, the strategy aims to: (1) reduce the prevalence of stunting to 25 per cent; (2) reduce wasting to less than 5 per cent among children under 5 years, and; (3) reduce the prevalence of iodine and vitamin A deficiency by 20 per cent among children under 5 years, adolescents, pregnant and lactating women and women of reproductive age. A stronger Logical Framework, Risk Management Framework and governance emphasis are designed to help achieve this. The new strategy’s time-frame extends from 2019 until 2025 and requires a total funding of USD 403,833,380 over six years of implementation, including higher levels of domestic financing, international funding and smarter public-private partnerships. 8 | P a g e VI. Introduction Sierra Leone implemented its first multi-sectoral National Food and Nutrition Security Strategic Implementation Plan (NFNSIP) during the period 2013—2017 as part of the country’s socio- economic investment in its human capital through coordination by its national Scaling Up Nutrition Secretariat (SUN) hosted in the Office of the Vice President. The Renewed Efforts Against Child Hunger and Undernutrition (REACH)/United Nations Network (UNN) in Sierra Leone has been supporting the Scaling Up Nutrition (SUN) Secretariat on nutrition governance and in strengthening coordination among sectors. In this context, REACH/UNN hired an international consultant to facilitate a consultative process to adequately review the NFNSIP 2013-2017 and to develop a new strategic implementation plan for the period 2019-2025. The specific objectives of the initiative were as follows: 1. To assist stakeholders in defining the overall goal, strategic objectives, indicators, and a set of nutrition actions by sector (nutrition specific, nutrition sensitive and enabling environment) that will contribute to the achievement of a common goal 2. To ensure the full involvement and ownership of all key stakeholders and partners in the process of developing the NFNSIP 3. To ensure that the goal, objectives, activities and indicators of NFNSIP are relevant, practical, measurable and achievable 4. To cost the implementation plan using costing methodologies and tools agreed upon by the Technical Working Group (TWG) 5. Facilitate the validation of the revised/updated National Food and Nutrition Security Implementation Plan 6. To develop the new updated National Food and Nutrition Security Implementation Plan. With full ownership and leadership by the Government of Sierra Leone, together with the financial and technical support from the Government of Ireland’s Irish Aid and strong participation by all stakeholders, this document is the result of this initiative. As agreed by all stakeholders consulted, this document is deliberately brief and concise in order to better focus the attention of implementers on their roles. Accordingly, a brief description of the review methodology is followed by a summary analysis of the situation and lessons learned, while the more detailed analysis of indicators and targets is provided in the annexes. Strategic priorities reflecting the key target populations, goal, objectives, strategic directions and priority activities represent the central part of this document, along with the results, monitoring and evaluation framework. The document ends with a risk mitigation framework and a summary budget which attempts to cost the strategic interventions at the level of objectives. This document is aimed at national and district-level policy-makers, legislators, senior as well as mid-level government and civil society (both international and national) technical staff along with key research institution professionals who are concerned with nutrition, food security, social protection and socio-economic development in Sierra Leone. It is expected that the document is a living document which will be implemented, co-owned, periodically updated (and, if necessary, adjusted) by all stakeholders throughout the 9 | P a g e implementation period. Rather than a comprehensive list of every single intervention needed to improve nutrition in Sierra Leone, this document provides the overall framework of priority interventions, districts, key populations and strategic directions from which all stakeholders at central and district level would elaborate their own detailed annual work plans and targets. VII. Review Methodology A chronology of key milestones for the development of this document can be found in Annex 10 and detailed data extracted from various sources are summarized in Annex 3 while list of reference documents consulted in this effort are found in Annex 1. Following the approved Country Implementation Plan (CIP) developed jointly by the UNN and the Government of Sierra Leone, REACH commissioned an international consultant recruited on 8th November 2017 to revise the expired National Food and Nutrition Security Implementation Plan (NFNSIP) 2013-2017 and to update it for the period 2019-2025. Stakeholder consultation and desk review of related literature Full involvement and ownership of all key stakeholders and partners was a key principle throughout the review and update process. Stakeholders’ consultative meetings were conducted between December 2017 and February 2018. In December 2017, extensive face-to-face stakeholder consultations were held, a Consultative Stakeholder Workshop was organized in Freetown and additional documents, inputs and strategic directions shared by all partners were reviewed by the consultant. From January – February 2018, consultations via email, phone and Skype were also conducted in the districts in order to solicit inputs from stakeholders missed during the face-to-face meetings. Additional clarifications and further inputs from stakeholders were also sought during this period. A desk review of related literature from documents collected during consultative meetings was done during this period as well. Overall, the process was successful in ensuring consultation of all nutrition-relevant sectors and all types of partners at both the central and district levels in Sierra Leone. Technical Working Group (TWG) establishment and Road Map development A TWG was created in November 2017. The TWG was led by the SUN Secretariat and composed of members from various Government line ministries, UN agencies, international non- governmental organizations, national civil society and research institutions as well as the private sector. The TWG was critical and useful in providing oversight to the review and update process based on a Road Map. In December 2017, a Road Map (RM) was approved by the TWG to chart the path towards achieving the objectives and addresses, both, substantive and logistical issues gathered during stakeholder consultation. The RM benefitted from a desk review of literature as well as extensive consultations held with SUN, UNN and key stakeholders in the food and nutrition security sectoral areas in Sierra Leone. 10 | P a g e Validation workshops Two validation workshops were organized. The first workshop was a Data Validation Workshop conducted on 26 February 2018 at the FAO Country Office Conference Room in Freetown. The workshop was conducted to review and validate most metrics and key planning elements of the new NFNSIP for 2019-2025 with key stakeholders, and a Summary Outcome Report was developed and attached as Annex 6. A second and final Full Validation Workshop was organized on 24 July 2018 where the first draft of the new Strategic Plan was approved. On 15th August 2018, a draft was developed based on stakeholders’ inputs during and after the last Full Validation Workshop. Synergies achieved with Sierra Leone’s emerging National Zero-Hunger Strategic Review Concurrent with the NFNSIP review and update, process, and with technical support by WFP, Sierra Leone is also developing its “National Zero-Hunger Strategic Review” which focuses on charting a path towards achieving the country’s nutrition-related Sustainable Development Goals (SDGs) by 2030. Taking advantage of the opportunity to harmonize their work, the teams responsible for both the NFNSIP and National Zero-Hunger worked closely to achieve as much synergy as possible. This collaboration included frequent consultations, sharing background documents and data, sharing results of district consultations, sharing the TWG’s role to oversee both work streams as well as mutual sharing of workshop and key milestone products. Ultimately, and although the time-frames for both processes differed slightly, the deliberate mutual effort resulted in reducing the burden on the shared stakeholders and in making both processes more efficient. Furthermore, the situation analysis as well as the proposed strategic directions and objectives of the new Strategic Plan are serving as a key input for the first part of the National Zero Hunger’s time-frame (i.e. up to 2023; as the National Zero-Hunger Strategic Review horizon is 2030). 11 | P a g e VIII. Situation Analysis This chapter provides Sierra Leone’s background and context. This is followed by a review of the policy landscape. A conceptual framework for analyzing nutrition challenges is then described before ending with an overview of findings from the review of the expired NFNSIP 2013- 2017. A. Country Situation Overview1 Sierra Leone is an agrarian economy with 61.1% of the labor force involved in agriculture, the majority of whom are involved in subsistence farming (SLDHS 2013). The main crops grown are rice, cassava, ground nuts, potatoes, yams, cocoa, coffee, corn and pepper while other notable economic activities are mining and fishing. The most recent national census conducted was in 2015, yielding a total population of 7,075,641 and a male: female ratio of 49%: 51%. Primary school enrollment rate is 85% and 73% of the total population live within 5 km of a health facility. Annex 2 provides an overview of Sierra Leone’s decentralized administrative units and health system. 2 Sierra Leone has not faced all the types of environmental realities experienced by some of its African neighbors, such as desertification lack of natural resource wealth. Yet, the country continues to face the effects of several key challenges, including extensive deforestation, loss of biodiversity, environmental damage from mining, changes in land use, doubling of the population in 35 years, accelerated urbanization, armed conflict (1991-2002) and the Ebola Virus Disease (EVD) epidemic (2014). As a fragile state, improving people’s livelihoods and increasing access to basic social and municipal services still remains a major challenge for policy makers in Sierra Leone today. Despite ambitious plans to enable its citizens to reap the dividends of peace and macro-economic growth, the country’s infrastructure, services and grass-root communities continue to struggle with both chronic structural barriers to sustained and equitable socio-economic development as well as repeatedly suffering shocks from armed conflict, epidemics and environmental disasters. Drawing on considerable natural wealth and promising potential capabilities, Sierra Leone had made good progress towards achieving the Millennium Development Goals (MDGs). For instance, in a continued trend since 1990, infant and child mortality are falling, maternal mortality is falling, births to adolescent girls are falling and overall life expectancy is 1 This section is based heavily on the FAO document by Zommers Z. PhD and Chand A PhD, “Review of Agriculture Related Policies in Sierra Leone”, FAO, January 2018 2 This preamble as well as the referenced Annex are based on the Situation Analysis section of the Government of Sierra Leone’s Master Plan for Neglected Tropical Diseases Elimination 2016-2020, Ministry of Health and Sanitation, 2016. Excerpt from the FAO document entitled: “Review of agriculture related policies in Sierra Leone” – FAO, January 2018 “By the end of the 1980s, the economy had almost collapsed and was characterized by declining GDP per capita, rapid inflation, and a severe external payments imbalance. Civil war ravaged the country between 1991 and 2002. While the country saw a period of recovery in the first decade of the 2000s, in 2014 the country faced an outbreak of Ebola virus disease (EVD). The EVD epidemic, accompanied by the collapse in the price of iron ore, bore a heavy economic toll. Real GDP shrank by an astounding – 21.1% in 2015. More recently, in August 2017, intense rainfall resulted in mudslides and flooding that killed over 500 people, damaged an estimated 350 buildings and left hundreds displaced. Additionally, the country now faces a new threat – the fall armyworm (Spodoptera frugiperda) – which has the potential to devastate agricultural production. These Excerpt from the FAO document entitled: “Review of agriculture related policies in Sierra Leone” – FAO, January 2018 “By the end of the 1980s, the economy had almost collapsed and was characterized by declining GDP per capita, rapid inflation, and a severe external payments imbalance. Civil war ravaged the country between 1991 and 2002. While the country saw a period of recovery in the first decade of the 2000s, in 2014 the country faced an outbreak of Ebola virus disease (EVD). The EVD epidemic, accompanied by the collapse in the price of iron ore, bore a heavy economic toll. Real GDP shrank by an astounding – 21.1% in 2015. More recently, in August 2017, intense rainfall resulted in mudslides and flooding that killed over 500 people, damaged an estimated 350 buildings and left hundreds displaced. Additionally, the country now faces a new threat – the fall armyworm (Spodoptera frugiperda) – which has the potential to devastate agricultural production. These continued shocks undermine the government’s ability to achieve SDG 2. “ 12 | P a g e improving3. If multi-sectoral actions to improve nutrition and health are seen as a major investment in human capital, the returns on such an investment could indeed enable Sierra Leone to become one of Africa’s countries on track to achieve the nutrition-related Sustainable Development Goals (SDGs)4 in 2030. B. Nutrition Conceptual Framework Addressing malnutrition starts first with understanding its causes. An evidence-informed approach and strategies to addressing nutrition and food security will be essential to achieve Sierra Leone’s ambitions. As it appeared in the African Union’s Africa Regional Nutrition Strategy 2015-2025 (ARNS), the following section illustrates the interrelationship between nutritional status with the proximal (immediate) and distal (underlying) factors that influence it. “The UNICEF conceptual framework for analysis of nutrition problems was used as the basis for the causal analysis in the ARNS. This conceptual framework as depicted in Figure 1 describes undernutrition as the immediate consequence of insufficient nutrient intake and disease factors. Both are the result of a number of underlying factors including limited availability and access to safe and nutritious foods, poor access to health services and unhealthy environment as well as inadequate care, especially of women and children. All these are rooted in basic factors, including adequate government commitment and resources that create the required enabling environment for nutrition security. The multi-sectoral nature of nutrition and the importance of nutrition governance/political economy at national and sub-national level, including policy reforms, are major features identified in the conceptual framework that have important policy implications. 3 Government of Sierra Leone, Ministry of Health & Sanitation Annual Health Sector Performance Report, p.21 (2016) 4 SDG Goal 2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture. Target 2.1 By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round. Target 2.2: By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons. Target 2.3: By 2030, double the agricultural productivity and incomes of small-scale food producers, in particular women, indigenous peoples, family farmers, pastoralists and fishers, including through secure and equal access to land, other productive resources and inputs, knowledge, financial services, markets and opportunities for value addition and non-farm employment Excerpt from the Africa Regional Nutrition Strategy 2015-2025, African Union Commission, Department of Social Affairs, July 2016 “In addition to food, there are many health and psychosocial care factors that negatively affect peoples' nutrition status and - unless these are effectively contained - will continue to hamper efforts to establish nutrition security in Africa. Food, health and care are consequently necessary, but each by themselves are not sufficient conditions for nutrition security. This important understanding of nutrition security was established in Tanzania already during the 1980s and was subsequently embraced by the UNICEF 1990 Nutrition Strategy and is now adopted as a globally accepted 'conceptual framework' for understanding the causes of malnutrition. A common version of this framework is presented in Figure 1. The implication is clear: there is no single sector or actor that by themselves can establish nutrition security but there has to be a well-coordinated effort across sectors and actors to ensure that inadequate food, health and care conditions are addressed when, where and in the way required. The imperative of a ‘multi-sectoral approach’ and a ‘multi-stakeholder platforms’ consequently needs to be adopted in nutrition policies and strategies across Africa. (There is a) …… need for strong and effective multi-sectoral governance and management structures and mechanisms for nutrition security……” 13 | P a g e Figure 1: Conceptual Framework for Analyzing the Causes of Malnutrition5 Underlying causes at household / family level Malnutrition Inadequate dietary intake Disease Insufficient access to FOOD Immediate causes Basic causes at societal level Conceptual framework for analysing the causes of malnutrition Outcomes Quantity and quality of actual resources – human, economic & organisational - and the way they are controlled Inadequate maternal & child CARE practices Poor water, sanitation & inadequate HEALTH services Potential resources: environment, technology, people TANZANIA JNSP/UNICEF In converting the above conceptual framework into an action framework, the ARNS 2015-2025 based its approach on a series about maternal and child health which had appeared in The Lancet journal since 2008. Figure 2 below clarifies how the nutrition-specific, nutrition-sensitive and enabling environment factors work to address the immediate and underlying causes of malnutrition. 5 Tanzania Joint Nutrition Support Program/UNICEF 1990; in African Regional Nutrition Strategy 2015-2025, Africa Union Commission, July 2016 14 | P a g e Figure 2: Nutrition-Sensitive Interventions & Nutrition-Specific Interventions:6 With some minor editorial changes, the excerpt from ARNS 2015-2025 below is provided as it is since it addresses precisely the strategic gaps needed in Sierra Leone’s new strategic plan for nutrition and food security: Experience in Africa has indicated that, in general, the over-dependency on a few selected nutrition specific interventions has not led to the expected improvements in the general levels of malnutrition. Limiting national responses to just nutrition-specific interventions is insufficient if the underlying and basic conditions are not addressed. Almost all cases of under-nutrition in Africa – at the level of the immediate causes (Figure 1) – result from inadequate intake of nutrients and disease factors. Therefore, it is important that Sierra Leone reviews its strategies and prioritizes more effective nutrition-specific) intervention approaches (particularly promotion of optimal infant and young child feeding practices, supplementation and fortification) as well as actions at the level of underlying causes, particularly the diversification of diets. The influence of maternal health on child nutrition is adequately documented and exclusive breast-feeding is clearly shown to effectively prevent stunting during the first six months after birth. In Sierra Leone, feeding inadequacy remains an issue and some studies have recommended that unplanned or unwanted pregnancies must be addressed more strongly, given that exclusive breastfeeding is less likely to be practiced by mothers who are not in a committed relationship.7 In addition, prevalence contraceptive rate by modern methods (mCPR) amongst all women in Sierra Leone was 25.8 percent, and the unmet need for modern methods 6 Lancet Series on Maternal and Child Nutrition 2013, cited in Africa Regional Nutrition Strategy 2015-2025, African Union Commission, Department of Social Affairs, July 2016. 7 IYCN Barrier Analysis, Western Area, HKI Report, 2013 15 | P a g e of contraception was 27.3 percent resulting in an estimated 56,000 unplanned pregnancies in 2017. 8 Child nutrition should also be seen as an integral part of child protection, whether it occurs in a humanitarian or a developmental context. Examples of such a link between child protection and nutrition interventions in emergencies include the training of social workers to identify malnutrition and awareness-raising on good nutritional habits in child friendly spaces, among other interventions. The “Minimum Standards for Child Protection in Humanitarian Action” regarding nutrition and child protection provides a comprehensive range of interventions and indicators to fulfill its following Standard: “Child protection concerns are reflected in the assessment, design, monitoring and evaluation of nutrition programmes. Girls and boys of all ages and their caregivers, especially pregnant and breastfeeding women and girls, have access to safe, adequate and appropriate nutrition services and food”9 C. Policy Overview Nutrition is reflected in various degrees in Sierra Leone’s national policies and strategies in the agriculture, health, education, social protection, HIV and AIDS as well as in other development sectors. While some of these instruments require updating, the fact that nutrition is recognized as a multi-sectoral issue is a positive sign. A recent policy review which was conducted by the UN’s Food and Agricultural Organization (FAO) in Sierra Leone in early 2018 examined 27 policies relevant to the agriculture sector in Sierra Leone. Policies were compiled based on consulting key stakeholders as well as government ministries and donors. The policy goals, and contents were then examined and compared to international goals and commitments. In relation to the nutrition area, the FAO policy review identified three sets of challenges. First, some of the well-evidenced essential core components of national nutrition action that were not sufficiently addressed in Sierra Leone’s NFNSIP 2013-2017, including food-for-work, cash-for- work and other key components of a comprehensive national response. Second, the review found that in NFNSIP 2013-2017 there had been too much of an emphasis on the health and agricultural sectors at the expense of a broader multi-sectoral rubric that should ideally frame nutrition strategies. Finally, the review also found that a major focus of the agricultural sector “… policies is sustainable production, with food security being only mentioned as a goal in two policies. By contrast, food and nutrition security is a major focus of recent international commitments such as the SDGs or the Malabo Declaration. In other words, the commitments and policies do not seem well aligned or integrated.”10 Furthermore, the same FAO policy review indicated that the challenges in Sierra Leone were related more to implementation than to the absence or weakness in policies relevant to food, agriculture and nutrition. Specifically, the FAO report states: “Since independence Sierra Leone has implemented numerous agricultural policies. In fact, according to an FAO review of past 8 The Way Ahead 2016-17 Annual Report. http://www.familyplanning2020.org/entities/96 (accessed June 17, 2018 9 Extract form the Minimum Standards for Child Protection in Humanitarian Action (full version available at http://cpwg.net/wp-content/uploads/2012/10/Minimum-standardsfor- child-protection-in-humanitarian-action.pdf) 10 Zommers Z. PhD and Chand A PhD, “Review of Agriculture Related Policies in Sierra Leone”, FAO, January 2018 http://www.familyplanning2020.org/entities/96 16 | P a g e agriculture policies in Sierra Leone, the country does not lack good policies. Instead challenges related to two broad areas continue to surface: (a) lack of stakeholder support (both financial and moral) for implementation; and (b) inadequate and poor capacity to sustain implementation and control exogenous factors. Policy problems that emanated from the first instance relate to policy parody, inconsistency, limited financial and material support and administrative mismanagement. Problems from the second instance come from issues relating to inadequate administrative capacity, limited research, inputs, and crop failures due to various shocks etc”.11 Some stakeholders mentioned that the new Strategic Plan is being developed at a time when the nutrition and food security policy had also expired in 2017. However, to avoid the risk of adding yet one more policy document to the numerous ones mentioned in the FAO review, it is best to avoid creating a stand-alone policy framework just for nutrition. Instead, it is more efficient if this new Strategic Plan is subsumed under Sierra Leone’s emerging Social Protection Policy Framework which also covers Strategic Plans for social sector initiatives, such as those for people with special needs, gender, HIV and orphans as well as the Child Welfare Policy of Sierra Leone. D. Multi-Sectoral Nutrition Situation Analysis Sierra Leone’s National Nutrition Survey 2017 (SLNNS 2017)12 provides the most up-to-date, comprehensive and accurate picture of the nutrition situation in Sierra Leone, in addition to evidence-based conclusions and recommendations. Other sources of information used in reviewing the progress in the expired NFNSIP 2013-2017 are shown in the Reference List in Annex 1. Annex 3 also provides a detailed, tabulated and itemized review for all indicators and targets used to assess the performance of NFNSIP 2013-2017. While some minor progress has been achieved in a few indicators, the large majority of targets was either not measurable (due to absence of data), available but stagnating at similar levels to those found at the 2013 baseline or (in a few cases) actually indicate a deteriorating situation. In an attempt to quantify the achievements made in implementing NFNSIP 2013-2017, a color- coding marks the detailed indicators and target tables found in Annex 3. In summary, there were 85 indicators and targets which were meant to be tracked in NFNSIP 2013-2017. Of these, there was no data available for 19 of the targets; 24 showed that the target was reached (green highlighted); 37 showed that the target was not reached (red highlighted) and 5 were equivocal or could not be deduced from the information provided (yellow highlighted). Even if it is generously considered that satisfactory achievement comprises the achieved targets (24) added to the equivocal targets (5), added to the targets for which 2017 or recent data were not available (19). This yields a total of 48 out of 85 (or just 56.5 %) targets which were achieved satisfactorily. Although the targets ought to carry different weight, they were listed in the NFNSIP 2013-2017 without allocating specific weights to each. 11 Zommers Z. PhD and Chand A PhD, “Review of Agriculture Related Policies in Sierra Leone”, FAO, January 2018 12 Sierra Leone National Nutrition Survey 2017 (SLNNS 2017). “….acute nutrition situation in the country is poor.. (and)……. chronic malnutrition as expressed by high stunting rates is serious…” - Sierra Leone National Nutrition Survey 2017 (SLNNS 2017) 17 | P a g e The following table summarizes the results of Sierra Leone’s recent National Nutrition Survey: Table 1 Summary of SLNNS 2017 Results Indicator SLNNS, Sep-Oct 2017 n % 95% CI Anthropometric Results based on WHO 2006 Standards (N=8993) Prevalence of Global Acute Malnutrition, GAM (WHZ<-2 or oedema), N=8974 455 5.1 4.6 – 5.6 Prevalence of Moderate Acute Malnutrition, GAM (WHZ>=-3 and <-2) 362 4.0 3.6 - 4.5 Prevalence of Severe Acute Malnutrition, SAM (WHZ<-3 or oedema) 93 1.0 0.8 – 1.3 Mean Weight-for-Height Z Score (WHZ) -0.10 ± 1.11 -0.13– -0.07 Bilateral Oedema 6 0.1 0.0 – 0.1 Prevalence of Global Acute Malnutrition based on MUAC (MUAC<125mm and/or oedema), N=8993 238 2.6 2.3 – 3.1 Prevalence of Moderate Acute Malnutrition based on MUAC (MUAC>=115mm and <125mm) 182 2.0 1.7-2.4 Prevalence of Severe Malnutrition based on MUAC (MUAC<115mm and/or oedema), 56 0.6 0.5 – 0.8 Mean Mid-Upper Arm Circumference (MUAC in mm) 150.6 ± 18.7 150.1 – 151.1 Prevalence of stunting (HAZ<-2), N=8961 2803 31.3 30.0-32.6 Prevalence of moderate stunting (HAZ>=-3 and <-2) 1910 21.3 20.3-22.3 Prevalence of severe stunting (HAZ<-3) 893 10.0 9.2-10.7 Mean Height-for-Age Z Score (HAZ) -1.41 ±1.29 -1.45– -1.37 Prevalence of underweight (WAZ<-2), N=8984 1221 13.6 12.8-14.5 Prevalence of moderate underweight (WAZ>=-3 and <-2) 946 10.5 9.8-11.3 Prevalence of severe underweight (WAZ<-2) 275 3.1 2.7-3.5 Mean Weight-for-Age Z Score (WAZ) -0.86 ±1.08 -0.89– -0.83 Mortality Results (Retrospective in 90 days prior to survey), N=8959 CDR (Total deaths/10,000 people/day) 0.19 0.15-0.24 U5DR (Deaths in U5 children /10,000 U5 children /day 0.16 0.10-0.27 Child Morbidity in two weeks prior to survey (N=9069) Prevalence of reported illness (6-59 months) 2007 22.1 20.3-24.0 Type of illnesses (N=2007): Fever 1506 75.0 71.7-78.4 Cough 717 35.7 31.7-39.8 Diarrhea 127 6.3 3.7-9.0 Other illnesses (skin, eye infections, etc) 379 18.9 15.7-22.1 18 | P a g e Table 2 Summary of SLNNS 2017 Results (continued) Indicator SLNNS, Sep-Oct 2017 n % 95% CI Health Programmes (N=9069) Children (9-59 months) immunized against measles: No Yes, with EPI card Yes, by recall Child <9 months 1973 5313 1171 612 21.8 58.6 12.9 6.7 18.9-24.7 55.1-62.1 10.5-15.3 6.2-7.3 Children who received vitamin A supplement 7278 80.3 77.6-82.9 Children who slept under net (LLITN) last night 8471 93.4 92.1-94.7 Proportion (12-59 months) dewormed in the last 6 months (N=7876) 5445 69.1 65.9-72.3 Infant and Young Child Feeding (IYCF) Practices (N=4550) Proportion of children (0-23 months) ever breastfed 4507 99.1 98.7-99.4 Proportion currently breastfeeding 4011 88.2 86.9-89.5 Proportion fed on colostrum (N=1106) 892 80.7 76.7-84.6 Proportion Exclusive Breast Feeding (N=1106) 681 61.6 58.0-65.1 Proportion bottle feeding 1058 23.3 20.9-25.6 Timely initiation of breastfeeding (with 1 hr of birth) 2585 56.8 52.8-60.9 Continued breastfeeding at 1 year (12-15 months) [N=510] 432 94.5 92.2-96.8 Timely introduction of complementary feeding (6-8 months) [N=426] 234 55.2 49.4-61.0 Proportion meeting minimum dietary diversity (6-23 months) [N=3444] 1023 29.7 26.6-32.8 Proportion meeting minimum meal frequency (6-23 months) [N=3444] 1518 44.1 41.2-46.9 Women Nutrition Status (N=9480) Acute Malnutrition by MUAC in PLWs (N=2770) 157 5.7 4.8-6.6 Acute Malnutrition by MUAC in non PLWs (N=6710) 10 0.1 0.0-0.2 Acute Malnutrition by BMI in non PLWs (N=6712) 345 5.1 4.5-5.8 Proportion meeting minimum dietary diversity for women (MDD-W), N=9496 6494 68.4 65.4-71.4 WASH Results (N=9467) Access to safe water source (Borehole, protected well/spring) 6491 68.6 64.8-72.3 Take recommended time (<30 minutes) to collect water (including queuing time): 7411 78.3 75.3-81.2 Appropriate treatment method (boiling, chlorination) 164 5.5 2.7-8.1 Mean amount of water (litres) used by household/day 82.5 ±57.3 79.1-85.9 Optimal (adequate) water use (15L/person/day) 5821 61.5 58.6-64.4 Access to sanitation facility (latrine/toilet) 1879 19.8 16.9-22.8 Hand washing at (at least 3) critical times: 2899 30.6 27.0-34.2 Hand washing with soap 6813 72.0 68.9-75.0 19 | P a g e Table 3 Summary of SLNNS 2017 Results (continued) Indicator SLNNS, Sep-Oct 2017 n % 95% CI Food Security Results (N=9469) Household’s main source of income: Sale of crops/farm produce Petty trading Skilled labour Salaried work 3298 1393 1315 850 34.8 14.7 13.9 9.0 31.5-38.2 13.2-16.2 11.9-15.8 7.6 – 10.3 Household’s main source of staple food: Purchases Own production Work for food/Labour exchange 6373 2683 110 67.3 28.3 1.2 63.8-70.8 25.1-31.6 0.7-1.6 Households that own livestock 3834 40.5 37.3-43.7 Households that cultivated in the current season 4543 48.0 44.4-51.6 Households that experienced some shock in the previous one year 1768 18.7 16.4-21.0 Households that applied at least one coping strategy in the previous 30 days 2019 21.3 18.7-24.0 Mean Reduced Coping Strategy Index (rCSI) 3.2 ±7.3 2.7 – 3.6 Level of coping strategies applied (rCSI) No or low (rCSI<4) Medium (rCSI of 4-9) High (rCSI ≥10) 7560 520 1389 79.8 5.5 14.7 77.2-82.4 4.2-6.8 12.5-16.9 Mean Household Hunger Scale (HHS) 0.7 ±1.2 0.6 – 0.8 Level of household hunger experienced (HHS) None or light Moderate Severe 7329 1993 147 77.4 21.0 1.6 74.5-80.2 18.4-23.7 0.7-2.4 Mean number of food consumption score (FCS) in past 7 days 53.7 ±17.4 52.3-55.0 Food security status based on food consumption Poor (FCS, 0-21) Borderline (FCS, 21.5-35) Acceptable (FCS, >35) 373 1021 8073 3.9 10.8 85.3 2.8-5.1 9.1-12.5 83.0-87.6 Mean household dietary diversity score (HDDS) in past 24 hours 5.3 ±2.3 5.1 - 5.5 More qualitative analysis of Sierra Leone’s current nutrition and food security situation reveals the following findings agreed upon by stakeholders: 1. The greatest burden of nutrition-related diseases appears to fall on rural populations, particularly rural women, with pockets of deep poverty and lack of access to nutrition and health services seen also among the urban poor; and in specific highly-vulnerable populations such as people living with chronic diseases, people with special needs, orphans, children and adolescents. Some of the vulnerability factors might also have a mutually-aggravating factor. For instance, the abuse of and violence against children involving nutritional neglect (often associated with unplanned or unwanted pregnancies); a dimension with which social workers and relevant child protection personnel should be aware. 20 | P a g e 2. At the upstream strategic level, the key drivers seem to include the need to ensure that political commitments, good governance and prioritized interventions are followed through at district and local levels, with a particular focus on equitable access to livelihood, social protection/safety net, disaster risk management, emergency situations and other nutrition-sensitive and enabling action areas. 3. In terms of types of malnutrition, Sierra Leone has remarkably low levels of iron deficiency among, both children and non-pregnant women (<10%) while vitamin A deficiency is moderate in children under five years (17.4%) and low among women of reproductive age (2%).13 Other positive findings in the implementation of the NFNSIP 2013-2017 are that early stimulation was included in the Nutrition-specific interventions as part of feeding and parenting behaviors and practices. Similarly, it is good that early childhood development (ECD) is included in Sierra Leone’s nutrition-sensitive interventions. 4. At the downstream implementation and intervention levels, opportunities remain largely unaddressed, including prioritizing nutrition interventions (particularly birth spacing to 36 months) during the first 1000 days of life from conception, improving water and sanitation, improving gender equality in educational attainment and income, reducing early marriages and adolescent pregnancy rates, control of communicable diseases, micronutrient fortification and utilizing schools as well as agricultural extension efforts to promote diversified dietary intake as well as to produce a broader range of agricultural products and ratification of a long-overdue national law to enforce the international code for marketing of breast milk substitutes. Also missed was the opportunity to prioritize key nutrition-relevant, policy-oriented research to clarify the influence on nutrition exerted by pollutants arising from intensified agricultural production, industrial (including extractive) and manufacturing sectors as well as elucidating entry points for social behavior change to improve breast feeding and household diet diversification. 5. Geographic (between and within districts), gender, cultural and socio-economic disparities are seen in many nutrition and food security indicators captured in SMART 2017 and other surveys. However, lack of gender disaggregation in NFNSIP 2013-2017 precludes any meaningful analysis of trends over time. 6. Based on available data, Sierra Leone’s water supply and sanitation needs to dramatically improve in order for it to reduce the diseases contributing to malnutrition. By the last quarter of 2015 (CFSVA 2015)14, only 61.8% of households in Sierra Leone had access to an improved water source and only 15.6% had access to an improved sanitation facility. At the end of 2017, only 5.5% of households were using adequate water treatment methods.15 7. A fresh perspective is needed to explain the stagnation of some nutrition indicators as well as addressing disparities in nutrition-related morbidity and mortality. Thus, it is important to consider all determinants of nutrition in the child survival framework in 13 Government of Sierra Leone, Ministry of Health and Sanitation, National Micronutrient Survey 2014 14 State of Food Security in Sierra Leone 2015 – Comprehensive Food Security and Vulnerability Analysis (data collected September-October 2015). This is a joint publication by the Government of Sierra Leone, WFP, FAO, AfDB, EU & WB. Urban access to improved sanitation was 43.9% while rural access was only 4.3%. 15 Sierra Leone National Nutrition Survey 2017 (SLNNS 2017) 21 | P a g e order to better understand how best to reduce the stunting, breastfeeding and some micronutrient deficiency rates. Sierra Leone’s persistent and high rates of anemia need to be further researched in order to better understand the relative contributions of environmental pollutants and infectious diseases. For instance, it has been demonstrated that infections such as malaria, acute respiratory tract infections and diarrhea are more involved in causing anaemia than iron deficiency in Sierra Leone16. Moreover, genetics are also a factor in the etiology of anaemia in Sierra Leone, including sickle cell anaemia and β-thalassemia17. Finally, food preparation and food chain-related processes are often contributors to some micronutrient deficiencies (including food harvesting, storage, processing and preparation practices). Sierra Leone’s National Neglected Tropical Diseases (NTD) Survey amongst school-aged children in 2016 indicates that Soil- Transmissible Helminths (STHs) have been brought under control (<20% prevalence; with less than 1% moderate or high intensity infections).18 Schistosomiasis has also been brought under control in 3 of the 7 endemic districts and reduced to moderate prevalence (>10%>50%) in the remaining 4 districts.19 The STH results were corroborated in an all age group survey in 2018.20 8. Similarly, equity needs to be addressed more deliberately and systematically through upstream/structural and downstream strategies captured in what should be a strongly pro-poor social policy in Sierra Leone. For instance, urban poverty and malnutrition seem to have different drivers, dynamics and entry-points for response in comparison with the rural scene, as exemplified by how the nature and extent of food safety concerns may differ between urban and rural areas. Routine food security surveillance data also shows geographic differentials in dietary intake, household access to food and other determinants of nutrition. Embedding food security and nutrition as a key pillar within the emerging social protection framework in Sierra Leone should be the kind of multi-sectoral platform where nutrition and food security can best be placed. Thus, cash and non-cash transfers (conditional and non-conditional) as well as accessing micro-credit and supportive social protection policies are all key types of nutrition- sensitive interventions that can have an impact in countries such as Sierra Leone. If data relevant to equity is regularly collected, analyzed and utilized in decision-making at central and district levels, better targeting of nutrition interventions will result while deteriorating trends can be anticipated and prevented or mitigated. 9. Creating effective demand for appropriate nutrition is highly needed and efforts such as information outreach, SBCC and nutritional education can and should be more efficiently and broadly delivered by systems that complement the health sector’s efforts, such as through schools, agricultural extension, market development and agro-business interventions. For instance, more nutrition education can be integrated within adolescent safe spaces, child-friendly spaces, life-skills training platforms, etc. 16 Wirth JP, Rohner F, Woodruff BA, Chiwile F, Yankson H, Koroma AS, Russel F, et al. Anemia, micronutrient deficiencies, and malaria in children and women in Sierra Leone PLoS ONE 11(5): e0155031. doi:10.1371/journal.pone.0155031 17 Wirth JP, Ansumana R, Woodruff BA, Koroma AS, Hodges MH, Association between sickle cell and β-thalassemia genes and hemoglobin concentration and anemia in children and non-pregnant women in Sierra Leone. BMC Research Notes (2018) 11:43 https://doi.org/10.1186/s13104-018-3143-x 18 Bah YB, Bah MS, Paye J, Conteh A, et al (2018) Control of soil-transmitted helminths in school age children in Sierra Leone after a decade of preventive chemotherapy intervention. Infectious Diseases of Poverty in press 19 Bah YB, Bah MS, Paye J, Conteh A, et al (2018) Schistosomiasis in school age children in Sierra Leone after six years of mass drug administration with praziquantel. Frontiers in Public Health - in press. 20 National NTDP and Children without worms (2018) All age STH survey report 22 | P a g e 10. Ebola’s impact continues to date in different forms in Sierra Leone, including donor fatigue, continuation of the short-term responses to longer-term challenges and nutrition, health and social issues that are often still managed in an emergency mode. Ebola has been evidenced in various studies to still affect malnutrition and food security, including through death of farmers or farm laborers, death of main income earners, continued hesitation of affected nursing mothers to breastfeed their infants, catastrophic costs of accessing care, Ebola orphans, reduction in purchasing power, reduction in productivity and other types of impact. Yet, and in order to fulfill the 2035 Agenda for Prosperity and achieve the SDGs in 2030, Sierra Leone must “build back better” (BBB) beyond just returning to its pre-Ebola developmental realities. 11. Private sector engagement has not been sufficiently broadened to unleash its true potential in Sierra Leone. Thus, while keen and capable extraction, construction, telecom and maritime industry actors abound in Sierra Leone, very few efforts have been made to systematically and sustainably create the kind or scale of public private partnerships (PPP) which can positively impact nutrition. Moreover, corporate social responsibility (CSR) by the private sector has not been well-guided by local and national priorities to invest in nutrition security in Sierra Leone. When and if leveraged strategically, such private sector engagement can harness the innovation, market influence and resources which the private sector can bring to interventions such as food fortification, crop diversification and demand creation for diversified dietary intake, protection against malaria and diseases related to poor sanitation or inaccessibility of drinking water and protection against environmental hazards. The private sector engagement should particularly target Sierra Leone’s local food producers and processors who have not been sufficiently addressed as a powerful ally. Thus, local production/processing has been largely ignored in favor of imported products for supplementation or therapeutic feeding programs. This is a slow process that should fall under ‘domestic resource mobilization’ ‘import substitution’ and ‘the local content act’ in the enabling environment pillar of the new strategy. Work on PPP should also be a cornerstone to addressing the increasing rates of obesity and overweight in Sierra Leone, for instance, by reducing the levels of trans-fats and hydrogenated (usually palm) oil in food products, better tobacco control, ratification and enforcement of the international code of conduct for breast milk substitutes and other evidence-based interventions which address risk factors for non- communicable diseases. Most importantly, PPP should not be merely seen as an additional envelope of financial or material resources. Rather, it is the private sector’s capacity, flexibility, speed of mobilization and technological innovation that represents the main added value it can bring to nutrition in Sierra Leone. It is hoped that some of these engagement challenges may start to be addressed through the opportunity presented by a recent formulation of a Food and Nutrition Security Business Working Group (BWG).21 12. The basic nutrition governance structures and capacities for coordination and management of a robust national response to such challenges require a much more 21 FAO Sierra Leone Country Office, Draft Concept Note for the “Food and Nutrition Security Business Working Group (BWG)”, December 2017. Draft Excerpt: “….(BWG) is a forum for private sector stakeholders working in agriculture and food and nutrition security in Sierra Leone to coordinate, share information and ideas and raise issues with other stakeholders (GoSL, UN agencies, donor agencies, multi- and bilateral organizations, NGOs, research institutions etc).” 23 | P a g e methodical, sustainable and focused approach in the new strategy. At central (i.e. national) and district levels, improving nutrition governance, management and coordination capacity will require a much stronger emphasis in the new Strategic Plan in order to enable the SUN Secretariat to perform its national role in a more effective manner. During the expired NFNSIP, situating the SUN Secretariat within the Office of the Vice-President provided sufficient visibility and signified the high-level commitment by the Government to address nutrition. There should be stronger emphasis to harmonize and align within the National Aid Policy framework and the development aid architecture in order to comply with global aid effectiveness frameworks. 13. In addition, the new strategy also needs a stronger capacity in the SUN Secretariat itself. Such a management capacity should aim at enhancing performance through a better skill- mix, more focused staff job descriptions and team performance tools that are used to further empower the staff, enable them to perform more effectively and ensure full accountability for their work. It is also crucial that district-level coordination of the SUN Secretariat’s work be considered a priority. 14. A higher increase in domestic financing is needed, as the current high dependency on international financing is both unnecessary and unsustainable for a sector seen by the country’s leadership as an essential part of the government’s commitment towards its most vulnerable citizens. Such an increase in domestic financing is possible, particularly if current budget support is better tracked and attributed to the indicators of performance in the new Strategic Plan for nutrition and food security. 15. Almost all stakeholders felt that the expiring NFNSIP for 2013-2017 contained sufficient detail and was comprehensive enough to address the large majority of needed multi- sectoral strategies and interventions for improving nutrition and food security in Sierra Leone. However, almost all stakeholders felt that prioritization of interventions was extremely important (particularly in rationalizing the nutrition-sensitive interventions, for instance, by using tools such as the SUN Secretariat’s Stakeholder Mapping exercise which identifies strategic gaps in Sierra Leone and using the Compendium of Actions in Nutrition which was developed by REACH in collaboration with technical teams from the agencies), attribution of specific performance benchmarks to specific actors and application of realistic costing parameters were not sufficiently addressed in the expiring plan. 16. Another design challenge in the expiring NFNSIP 2013-2017 is that it mentioned some but did not sufficiently build-upon and link existing interventions and projects with the new ones it had proposed. Hence, rather than appearing to be a stand-alone framework for action, the new strategic implementation plan should create a framework within which all existing and new interventions feed into a collective multi-stakeholder and multi-sectoral effort which achieves a set of national objectives. At the same time, the new strategy should ensure that cumulative performance in each of these projects can be amalgamated to track progress towards achieving the overall objectives as well as to maintain intervention continuity and sustainability. 17. Finally, the strategic information and evidence-base of the new Strategic Implementation Plan should benefit from recent Sierra Leone’s National Micronutrient Survey (2014), the various nutrition barrier analyses for IYCF (infant and young child 24 | P a g e feeding; performed 2013-2017), the recent National Nutrition Survey 2017 (SLNNS 2017) in addition to other surveys and assessments. Within the new plan, it will be more sustainable and efficient to expand the scope and improve the capacity of the existing nutrition and food security surveillance systems led by the Government, instead of relying on frequent, laborious and expensive cross-sectional studies. IX. Lessons Learned, Challenges & Opportunities In the following excerpt and related Text Box, the African Union’s Africa Regional Nutrition Strategy 2015-2025 cites some important lessons learned which Sierra Leone needs to consider. “Some countries in Africa (including Senegal, Ethiopia and Rwanda) have recorded significant reduction in stunting during recent years. All of these countries are very different albeit similar within a wider African political, geographical, cultural and social context. They all have been implementing ‘typical’ national nutrition programs with a ‘package’ of (primarily) nutrition specific interventions …. alongside integrated management of childhood illnesses. The same package, however, is implemented in most other African countries, which have not recorded such significant reductions in levels of childhood stunting. What is special about these countries is the ….. ‘good development practices’ which they implemented in a concerted manner and not one-by-one” (Please see Text Box). Some of the lessons gained during the review of NFNSIP 2013-2017 were already covered during in the Situation Analysis chapter (e.g. nutrition governance, Ebola, strategic information gaps, design challenges, etc). Others were gleaned from the implementation of the expired NFNSIP 2013-2017. Sierra Leone needs to better understand the contextual barriers preventing the uptake of such practices and to then address those barriers through development and implementation of social and behavioral change and communication as well as other interventions. The review of, both, the NFNSIP 2013-2017 and the stakeholder consultations revealed the following key lessons: 1. Nutrition governance, management and coordination, along with the political will that enables them, are fundamental building blocks for the success of even a well-designed, reasonably-funded Strategic Plan. 2. In a decentralized governance structure, empowering district level action is essential for achieving successful implementation and, even then, can only succeed if it involves devolution of resources, funding, capacity and authority (not just responsibilities,) development actions, including nutrition actions. “Good Development Practices” to reduce stunting in Africa (based on AU ARNS 2015-2025, AUC, July 2016) 1. highest level of political leadership with explicit priority for nutrition; 2. making government functionaries accountable for results on nutrition; 3. putting in place an effective primary health care system that extend to almost every village (i.e. wider coverage); 4. including nutrition as part of the job description of village health workers; 5. actively addressing food security issues; 6. emphasizing a participatory rural development approach with strong community structures; 7. pursuing decentralization based on local capacity development; 8. accelerated primary school enrolment with special emphasis on girls’ education; 9. implementing other programs for women’s empowerment (control of female genital mutilation, FGM, support to microcredit for women, etc.); 10. initiated strong poverty reduction/social protection programs. 25 | P a g e 3. Reducing stunting requires as a fundamental element the promotion of early initiation of breast feeding, ensuring complementary feeding is appropriately practised, control of internecine infections (including water, sanitation and hygiene practices) that result in failure to thrive as well as prevention of unwanted pregnancies by providing better access to quality family planning counselling. 4. The continuum encompassing the First 1000 Days of Life is not just a logo; it is a scientifically-proven span of intervention requiring actions to protect both mother and child from malnutrition, starting with the antenatal care visits, through delivery, postpartum and neonatal periods, through infancy and early childhood. 5. Adolescents (particularly girls) are crucial as both, agents for change in their families and among their peers as well as future mothers and fathers whose nutritional status must be addressed in a focused manner in the new Strategic Plan. 6. The intersection of poverty, gender, socio-economic class and geographic disparities requires a planning approach that deliberately and forcefully addresses equity of access to nutrition security. A blanket approach for the whole country would not address the unique needs of the most vulnerable. 7. The governance and implementation of nutrition and health services remain as key challenges in the post-Ebola Virus Disease EVD era in Sierra Leone. This is particularly important in light of how the deep shocks from the 2014-2016 Ebola Virus Disease EVD epidemic continue to have grave effects on lives, livelihoods, community resilience and household access to service delivery. 8. It is important to sustain the effort as well as the resources, behaviors and action platforms it has created. This is particularly important for the behavioral elements whereby there is a critical mass of Sierra Leonean mothers and families who continue to express effective demand for good nutrition practices. One way to address that is to increase the buy-in by children, adolescents and youth in higher education on the importance of good nutrition and ways to achieve it in their families and communities. Other ways include reinforcing good nutrition education in schools, farming associations, women’s support groups and in society at large. Sustainability is also of equal importance when it comes to mainstreaming the nutrition governance structures and functions (including accountabilities) into more durable mechanisms at national, district and community levels. In other words, the sustainability is not just needed for maintaining the stock of commodities, personnel and services who implement nutrition programs in Sierra Leone. 26 | P a g e X. Strategic Priorities The Strategic Priorities of Sierra Leone in the new Strategic Plan consist of a focus on certain population groups, a clear goal that is linked to African and global commitments, a limited (and thus practical) set of Strategic Objectives and a set of Strategic Directions that guide the Priority Activities to be implemented. The Logical Framework is attached as Annex 8 and it enables effective monitoring of progress towards achieving the objectives. A. Key Target Populations In the new Strategic Plan, the following population groups are to be prioritized in the fight against maternal, child and adolescent malnutrition: • Newborns and children under 5 years of age, Adolescents (particularly, but not exclusively, girls); • Women of reproductive age; • Persons with special needs (including people living with HIV or TB, mentally or physically-challenged persons, orphans and vulnerable children and others); • Internally displaced persons (IDPs) and returnees; • Urban poor; • Female heads of households (particularly, but not exclusively in rural areas), and; • Victims of natural and man-made disasters A. Goal Stakeholders consulted during the review and update process have unanimously agreed about the importance of demonstrating how Sierra Leone’s Goal and Strategic Objectives contribute to continental African and global commitments. These include the African Union’s African Health Strategy 2016-2030, the 2014 Malabo Declaration and the African Regional Nutrition Strategy 2015-2025 in addition to nutrition-relevant global initiatives and commitments such as the Sustainable Development Goals (SDGs). These commitments are as follows: Objectives of the AHS 2016-203022 Strategic Objective 2: Reduce morbidity and end preventable mortality from communicable and non-communicable diseases and other health conditions in Africa by implementing the following strategic priorities: (only the most directly-relevant of several “strategic priorities” in the AHS 2016-2030 is shown here): • Reducing all forms of malnutrition including stunting among young children and related nutrition objectives as specified in the Africa Regional Nutrition Strategy (2016-2025) Objectives and Targets of the ARNS 2015-2025 • 40% reduction of the number of African children under 5 years who are stunted by 2025; • 50% reduction of anaemia in women of child-bearing age in Africa by 2025; • 30% reduction of low birth weight in Africa by 2025; • No increase of overweight in African children under 5 years of age by 2025; • Increase exclusive breast-feeding rates during first 6 months in Africa to 50% by 2025; • Reduce and maintain childhood wasting in Africa to less than 5% by 2025. 22 African Health Strategy 2016-2030, African Union Commission, Department of Social Affairs, July 2016 27 | P a g e Objectives and Target of the 2014 Malabo Declaration23 “…..to improve nutritional status, and in particular, the elimination of child under-nutrition in Africa with a view to bringing down stunting to 10% and underweight to 5% by 2025”. Objectives and Targets of the Sustainable Development Goal 2 (SDG 2) End hunger, achieve food security and improved nutrition and promote sustainable agriculture. • Target 2.1 By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round. • Target 2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.24 • Target 2.3 By 2030, double the agricultural productivity and incomes of small-scale food producers, in particular women, indigenous peoples, family farmers, pastoralists and fishers, including through secure and equal access to land, other productive resources and inputs, knowledge, financial services, markets and opportunities for value addition and non-farm employment. The Goal statement for the new NFNSIP 2019-2025 should therefore explicitly reference all the above, in addition to the UN Global Strategy for Maternal, Newborn, Child and Adolescent Health with which the SDGs are aligned. It will be equally important to organically link the new Strategic Plan to a higher national vision and broad developmental policy framework (eg poverty-reduction, social policy, etc) that are similar to Sierra Leone’s “Agenda for Prosperity”. It was agreed by all stakeholders that the Objectives for the new Strategic Plan for 2019-2025 should best be based on the ARNS 2015-2025, given that its time-frame is closest to the new NFNSIP while the choice as well as the value of its indicators have already been harmonized with the SDGs and the UN Strategy. In light of the above, and based on stakeholders’ consultations, the following overarching Goal is recommended for the new NFNSIP: “To contribute to the African Union’s Africa Regional Nutrition Strategy (2015-2025), the UN Sustainable Development Goals by 2030 and the UN Global Strategy for Maternal, Newborn, Child and Adolescent Health (2016-2030) by accelerating and scaling-up nutrition action across all sectors in Sierra Leone” B. Objectives & Intermediate Result Strategic Objective SO1: By 2025, to reduce the prevalence of stunted children under 5 years of age (U5C) to 25% from 2017/18 baseline levels. Strategic Objective SO2: By 2025, to reduce the prevalence of wasting among children under 5 years of age (U5C) to less than 5% from 2017/18 baseline levels. 23 Malabo Declaration on Accelerated Agricultural Growth &Transformation for Shared Prosperity & Improved Livelihoods, African Union Commission, Malabo, Equatorial Guinea, June 2014 24 SDG Target 2.2 calls specifically for: 40% reduction of stunting; 50% reduction of anemia; 30% reduction of LBW; EBF at minimum 50%; child wasting < 5%; no increase in child obesity 28 | P a g e Strategic Objective SO3: By 2025, to reduce by 20% the prevalence of iodine and vitamin A deficiencies in U5C, adolescents, PLW25 & WRA from 2017/18 baseline levels. Intermediate Result26: To create an enabling environment for central and district multi-sectoral coordination, promotion and action C. Strategic Directions & Priority Activities In order to achieve the above-mentioned Goal and Objectives, the following Strategic Directions and corresponding Priority Activities are necessary to be implemented. They are divided into Nutrition-Specific, Nutrition-Sensitive and Enabling Environment as per the Conceptual Framework shown above in section VIII (“Situation Analysis”) under the sub-section “B. Nutrition Conceptual Framework”. Within 3 months following the approval of this new Strategic Plan, the SUN Secretariat in close consultation with stakeholders will develop and submit to the Steering Committee a detailed Annual Work Plan which elaborates the priority interventions into a Gantt Chart based on the Results Monitoring and Evaluation Framework and the Risk Management Frameworks shown in the subsequent chapters of this document. It is important to note the deliberate and significant synergy exists between this new Strategic Plan and the Ministry of Health and Sanitation’s Reproductive, Maternal, Child, Newborn and Adolescent Health RMNCAH Implementation Plan 2017-2021 (including, but not limited to) the latter’s following Objectives, Strategies, Key Actions and Activities: Objective 1: Strengthened health systems for effective provision of RMNCAH services Strategy 1.1. Adequate, skilled and motivated HRH27 1.1.3. National RMNCAH task shifting and task sharing 1.1.3.2 Training and upskilling of nurses to the Midwifery Technicians cadre. 1.1.3.3 Train and retrain 400 HCW (SECHNS and MCH Aides) yearly in PHU on long lasting family planning methods particularly targeted at adolescents. 1.1.3.4 Training of 300 HCW on short term family planning methods yearly in PHU, particularly the adolescent age group. Objective 3: Strengthened community systems for effective RMNCAH service delivery Strategy 3.1. Sociocultural, geographical and financial barriers to access and utilization 3.1.1. Targeted national social and behavior change communication 3.1.1.3 Partner with religious leaders to address harmful practices especially early child marriage, GBV and FGM among adolescents. 3.1.1.4 Partner with and support mother support groups to promote positive behaviors such as EBF, delivery at health facilities, postpartum FP among others. 3.1.1.5 Support innovative interventions such as working male champions to ensure male involvement and engagement in RMNCAH. 25 PLW = Pregnant or Lactating Women; WRA = Women of reproductive age 15-49 years; U5C = Children under 5 years of age 26 While some stakeholders felt that the Enabling Environment pillar should have its own objective, most stakeholders agreed in the Final Validation Workshop that its nutrition government interventions are a means, not an end, to achieve the other two Strategic Objectives. 27 HRH=Human Resources for Health 29 | P a g e 3.1.1.6 Train community health workers to provide targeted messages to address sociocultural barriers to uptake of RMNCAH high impact interventions. Strategy 3.2. iCCM plus, per community health policy and strategy 3.2.2. Commodity security for iCCM implementation. 3.2.2.2 Support procurement and distribution of adequate iCCM supplies and commodities including equipment such as MUAC tapes, height boards, weight scales etc. 3.2.4. Community health worker supervision. 3.2.4.1 Train CHWs supervisors from priority districts on iCCM. 3.2.4.2 Facilitate CHWs supervisors to conduct supportive supervision to motivation for iCCM plus CHWs in all districts 3.2.4.3 Facilitate availability of iCCM supervision tools in 7 districts. 3.2.4.4 Support payment of CHWs incentives in priority 7 districts. 3.2.4.5 Support payment of CHWs peer supervisors’ incentives in all districts. 3.2.5. iCCM data collection, analysis, reporting and documentation 3.2.5.1 Support printing and distribution of CHWs data collection and reporting tools in 7 districts. 3.2.5.2 Training of CHWs and supervisors on data collection, analysis and reporting in 7 districts. 3.2.5.3 Provide transport and allowances to CHWs to facilitate data collection, analysis and reporting meetings. Strategy 3.3. Implementation of interventions at community level 3.3.1. Capacity of CHWs to implement RMNCAH interventions 3.3.1.1 Support development of necessary curriculums, tools/job aids, IEC materials for CHWs on provision of RMNCAH high impact interventions as per the CHW policy. 3.3.1.2 Implement technical modules training for CHWs to increase their capacity to offer RMNCAH high impact interventions such as essential newborn care services. 3.3.1.3 Provide training and sensitization of community health workers on provision of adolescent responsive services at community level including counselling and interventions for teenage pregnancy prevention. 3.3.2. Social accountability and action at community level. 3.3.2.1 Support Community mobilization on need for social accountability for RMNCAH. 3.3.2.2 Pilot training of community health committees, Facility Management Committee (FMCs), CHWs and other structures on RMNCAH score card. 3.3.2.3 Pilot use of community score card for accountability at community level. 3.3.2.4 Pilot train and support village health committees to monitor and report RMNCAH service delivery at community and facility level. 3.3.2.5 Training of CHW on community-based surveillance for maternal, perinatal and child deaths at community level. Strategy 3.4. Other sector determinants to access and utilization of services 3.4.1. Functional multisectoral platforms at community level 3.4.1.1 Support community mobilization for formation of multisectoral platforms for RMNCAH at community level. 3.4.1.2 Support orientation of the multisectoral platforms on their terms of reference and mandate services. 30 | P a g e 3.4.1.3 Quarterly meeting of the RMNCAH multi-sectoral working group at National level to develop, review and implement action plans to address multi-sectoral bottlenecks to access and utilization of RMNCAH high impact interventions. 3.4.1.4 Facilitate with MEST the development of CSE curriculum and its implementation. 3.4.2. Pilot and document promising multi-sectoral interventions at community level. 3.4.2.1 Support assessment of opportunities for RMNCAH multi-sectoral interventions in selected districts. 3.4.2.2 Support integration of social protection interventions and RMNCAH in 4 districts 3.4.2.3 Support implementation of model adolescent health and education sector multi- sectoral response in 4 districts 3.4.2.4 Support the construction of water, sanitation and hygiene interventions in districts (borehole, water tank and piping). 3.4.2.5 Support the transitioning of campaign-based vitamin A supplementation and deworming among children under-five to integrated routine-based reproductive and child health services at the six-monthly point of contact. NUTRITION-SPECIFIC STRATEGIC DIRECTIONS & PRIORITY ACTIVITIES: SD 1: Intensify promotion of optimal care practices affecting nutritionally-vulnerable groups 1. Based on existing and new operations research, determine key factors (knowledge, attitude, practices, barriers and enablers) affecting maternal, infant and young child feeding and care practices (including sanitation and hygiene practices) then develop and apply an appropriate SBCC strategy and plan to address these factors 2. Improve delivery of holistic baby and child friendly services at all levels (including early childhood development programs such as parenting program and early stimulation) 3. Improve the nutritional status through appropriate complementary feeding practices of children under the age of 5 years, pregnant and lactating women and women of reproductive age (15-49); with a particular prioritization of initiation of breastfeeding within 1 hour of birth, exclusive breast feeding for at least the first 6 months, including by effectively addressing taboos and myths around food for young children and universal coverage of quality FP counselling and provision. Strengthen preventive measures against nutrition related diseases. 4. Improve access to quality curative nutrition services. SD 2: Strengthen health and community development systems to ensure a holistic and responsive delivery of services in conducive and safe environments 1. Support efforts to ensure well-functioning national health and nutrition systems, following a comprehensive and integrated health systems strengthening approach 2. Intensify programs which prevent diseases affecting children, adolescents and women 3. Timely and comprehensive management of illnesses affecting children and women ensuring the integration of services which address nutrition with those addressing RCH services as well as communicable (particularly malaria, HIV, TB, NTD control services) and non- communicable disease control (especially obesity-related lifestyle interventions in urban settings) 4. Increase access to quality FP counselling, ante-natal care, intrapartum and post-partum care, including breast-feeding counseling, newborn health, immunization for mother plus routine VAS for children 31 | P a g e 5. Scale-up and rapidly expand IMNCI28 6. Link nutrition awareness-raising with adolescent education by engaging them in activities such as adolescent safe spaces, girls’ and boys’ clubs 7. Rapidly increase access to safe drinking water and hygiene and sanitation by improving water sources, reducing the number of communities practising open defecation, promoting handwashing with soap, strengthening WASH facilities in schools as well as health facilities, training and equipping facility user committees to ensure continuous operation and maintenance of installed WASH29 facilities. NUTRITION-SENSITIVE STRATEGIC DIRECTIONS & PRIORITY ACTIVITIES: SD3: Improve household food security especially of households with multiple overlapping factors influencing their food security status 1. Improve household food security situation (quantity, quality and safety) in order to satisfy the daily dietary needs of the population; including by expanding general food distribution to households through either cash vouchers or direct food distribution to supplement household food stocks in priority districts; at least during the leaner months of the agricultural season, among vulnerable households, etc. 2. Strengthen crop, food diversification, and bio-diversification initiatives 3. Scale up appropriate technologies used to improve food quality & quantity (eg fortification) 4. Promote food safety and hygiene practices such as safe food preservation, storage and preparation methods 5. Strengthen capacity of ministries involved in local food production and trade so that they lead the production and distribution of nutritious food items, introduce/scale-up appropriate technologies for food fortification, enforce proper quality assurance and food safety measures as per national standards. SD 4: Rapidly increase access to adequate nutrition among target groups by leveraging existing efficient education and social sector service delivery platforms 1. Assess nutritional status, dietary practices and patterns of physical activity of school-age children 2. Improve the coverage and quality of education including access to education of girls and comprehensive sexual education (CSE) with the education curricula 3. Expand and intensify school feeding for all children and adolescents to specifically include all pre-primary schools through junior middle school. 4. Scale–up and support school gardens, collaborating with the private sector in each district 5. Improve targeted, nutrition-sensitive and gender-sensitive social safety net programing that includes increasing access to credit, cash transfers, microfinance and other income- generating initiatives to vulnerable groups as well as increasing access to basic nutrition services for all vulnerable groups 6. Utilize the new Social Protection Framework to ensure cash-based incentives for education of children and adolescents (particularly girls) 7. Scale-up establishment & maintenance of quality WASH structures & systems at all levels ENABLING ENVIRONMENT STRATEGIC DIRECTIONS & PRIORITY ACTIVITIES: 28 Integrated Management of Child and Newborn Illnesses 29 WASH=Water Supply, Sanitation and Hygiene 32 | P a g e SD5: Prioritize action to strengthen district capacity in nutrition: 1. Target the districts identified in the CFSVA (Country Food Security & Vulnerability Assessment; 2016) and SNNS (2017) which are food-insecure30 and 50% of other districts experiencing worst acute malnutrition and stunting levels. 2. Deliver focused sustained support to these districts in order to significantly strengthen their capacity to manage, coordinate, develop and deliver integrated, multi-sectoral, multi- stakeholder, nutrition-specific & nutrition-sensitive interventions involving at least health, agriculture, education, water, sanitation, gender/labor/social welfare sectors. SD6: Urgently undertake legislative, governance and executive actions to create the necessary enabling environment in support of multi-sectoral nutrition 1. Adapt the new NFNSIP 2019-2025 to and subsume it as an integral part of the emerging national social protection policy and social protection framework while ensuring that other policy frameworks and policy reform deliberately integrates nutrition security (eg into national policy frameworks and strategies for the National Child Welfare Policy along with strategies on other cross- sectoral strategies such as those for HIV and AIDS, gender, disaster risk management, disability etc). 2. Advocate for the development and/or strengthen the coherence of policies and legislation affecting food and nutrition (e.g. Legislation Regulation of the Marketing of Breastmilk Substitutes, National Policy on Salt Iodization, etc) 3. Consistently emphasize, explicitly-reference and incorporate clear accountabilities for nutrition within other sectoral and inter-sectoral policies and strategic frameworks/plans (particularly in health, agriculture, food security, livelihoods, water supply, sanitation, education, etc), including through inter-ministerial adoption by the Cabinet and subsequent approval by Parliament of the new strategic plan and its accountabilities. 4. At both central and district levels, foster effective coordination mechanisms which effectively engage and mobilize multiple sectors (e.g. water supply and sanitation, agriculture, food security/livelihoods, education, health, social protection, child protection, etc.) and multiple stakeholders (civil society, development partners, government, private sector), community mechanism such as the Child Welfare Committees and other relevant actors in those coordination mechanisms. 5. Increase the magnitude and transparency of domestic resource mobilization, allocation and disbursement for the effective and efficient delivery of nutrition-related services, while also significantly increasing and incorporating formal transparent accountabilities for the flow and utilization of domestic financial and non-financial resources in support of nutrition, including by ensuring budget lines within each Ministry are dedicated to F&NS and that specific account codes for nutrition and food security are created within key line ministries such as the MOHS. Domestic resource mobilization also means sourcing commodities for interventions locally as much as possible and, therefore, should include prioritizing local content in both supplementary and therapeutic feeding programs. 6. Improve evidence generation and utilization at national and district level for informed advocacy, planning and intervention actions supporting nutrition. This should focus on strengthening the early warning systems for food and nutrition information from community to national level, operations research led by national institutions to clarify barriers to breastfeeding, early childhood and pregnancy-related nutrition as well as by ensuring that 30 Based on the regular Ministry of Agriculture, Fisheries and Forestry monitoring supported by the UN’s World Food Program in Sierra Leone. 33 | P a g e all data and research reports are gender-responsive enabling disaggregation of statistics and action by gender 7. Proactively engaging and increasing the role of existing community mechanisms. district councils, parliament, the media and civil society across all development sectors in monitoring progress towards nutrition advocacy goals & objectives; This should include increasing the commitmentfrom policymakers, policy advisors, and multi-sectoral programme designers at national district and sub-district levels to accord food and nutrition security (F&NS) a high priority in the political and national development agenda: 8. Orient new parliamentary members, while identifying and engaging F&NS champions through the parliamentary network as well as consistently advocating for the necessary parliamentary F&NS action that advances nutrition and food security 9. Ensure the all F&NS (SUN) focal persons within EACH Ministry meet at least quarterly with an emphasis on sustainability and seniority of focal persons. 34 | P a g e XI. Results Monitoring & Evaluation Framework (RMEF) This section analyses the design and management challenges identified during the review of the expiring NFNSIP 2013-2017. To address these, the new strategy utilizes a more realistic Logical Framework (attached as Annex 8) and provides a Risk Management Framework to minimize the managerial and accountability challenges. Together, these elements aim to strengthen the governance, coordination and management of the new Strategic Implementation Plan. Nutrition governance, aid effectiveness principles (especially mutual accountability and transparency) together with a robust, results management framework are critical if harmonized efforts of development partners are expected to align with a cohesive, integrated and well- governed strategic implementation plan. According to the AU’s Africa Regional Nutrition Strategy 2015-2025, “Nutrition governance is first and foremost about governments but then needs to define more precisely what particular aspects of government responsibilities are critical for the purpose of effective management of multi-sectoral nutrition actions”. The UN Network, REACH, defines Strong 'nutrition governance' countries as those where the government has recognized that they are responsible for ensuring that their citizens’ right to nutrition security is realized and to that end, has: ➢ Committed to having a national nutrition action plan, which is also part of the national development strategy, on how to fulfill their commitment; ➢ Set up inter-sectoral coordinating committees; ➢ Established multi-stakeholder mechanisms to ensure effective participation; ➢ Allocated budget lines for nutrition strategies and plans; and ➢ Conducted regular assessments and surveillance to ensure the efforts are leading to improved food and nutrition security for all.” A combination of governance, management and coordination challenges had prevented stakeholders from effectively managing the expired NFNSIP in order to achieve results. Most were design failures; including the following: 1. Unrealistic expectations: Too many interventions, too many indicators and too many inappropriate indicators (i.e. not S.M.A.R.T), combined with low capacity (and poor coordination culture/team work) at national and district level to effectively manage and deliver the results. 2. Resource constraints unaccounted for: Even if developmental shocks are excluded (e.g. Ebola, mud-slides, etc.), the required effort to achieve some key indicators required additional human and financial resources at district and sub-district levels. The necessary resources to implement that effort were either not planned or not received, including additional health and community workers, additional district staff, operational finances and others. 3. Insufficient empowerment of sub-national managers: By January 2018, most district stakeholders did not see the NFNSIP 2013-2017. No district-level, measurable and time- bound work plan exists for which district-level managers can be appropriately resourced, trained and held accountable to implement (by both local District Councils or by national 35 | P a g e authorities). Only a “Summary of five-Year costed Implementation Matrix” (Table 28) was included. However, the detailed budget was not included in the printed version. Hence, it was not seen even among the few district-level stakeholders who actually saw the NFNSIP document. 4. Inadequate Logical Framework: Women, adolescents and children above 5 years of age were almost completely missed in the articulation of impact and elsewhere. With reference to the color code guide added in the right-hand margin of the Logical Framework of NFNSIP 2013-2017, the following is a summary of the types of inadequacies found in the Logical Framework of the NFNSIP 2013-2017: ➢ Unrealistic targets ➢ No targets for important & readily-measurable indicators ➢ Vague indicators & ineffective verification means ➢ Inconsistent & poorly-expressed targets ➢ Indicator in numbers while targets in percentages ➢ Some Assumptions should be precursor activities ➢ Combined Output Indicators (OIs) necessary but insufficient to achieve the Output (ie incomplete/inappropriate OIs) 5. Inadequate attribution of responsibilities among the implementing stakeholders: The NFNSIP 2013-2017 had a section on roles and responsibilities under each of the priority areas in the narrative. It also had a (very limited) set of activities which will be implemented “as part of” the NFNSIP. Neither the roles and responsibilities nor the activities section used time-bound, specific targets and both were often generic statements about the statutory roles routinely performed by these responsible institutions, as opposed to a specific focus captured in a Strategic Implementation Plan. Moreover, neither the logical framework nor the M&E plan sections included activities; they both reflected just the impact, outcomes and outputs. They were both also devoid of any time-line for implementation or any logical sequencing of activities spread over time. Most features in both the logical framework and the M&E plan were duplicated to the extent that they hardly add to one another’s value. 6. Risks & Risk Mitigation Measures: Almost totally lacking from the NFNSIP 2013-2017 document is the concept of risk management; an essential tool for planning and success. The NFNSIP is not intended to be a source of fresh financing streams for national commitments to fight malnutrition. Rather, it is a catalytic framework and process whereby national and subnational leadership can better design, adopt, integrate, scale-up, coordinate and manage their own commitments, actions and resource investments aimed at achieving better nutrition and development outcomes. As such, the workshop recommended that the new NFNSIP 2019- 2025 should be governed based on the following principles and key features: a. The design of the new NFNSIP as well as its Logical Framework should be much simpler and more concise, enabling better results-based management and greater transparency as well as accountability. It must account for emergencies, contingencies, resource constraints, human resource capacity (especially at district level) and the necessary measures to mitigate shocks that affect human and financial resource availability during implementation and monitoring. Indicators should be SMART (specific, measurable, appropriate, realistic and time-bound); as well as linked with regional (Africa-wide) and global indicators (eg SDGs and EWEC) for comparability. 36 | P a g e b. A conceptual framework to analyze nutrition in the new NFNSIP should show how nutrition- sensitive, nutrition-specific and enabling environment factors interact, and is used as a basis for the Logical Framework. c. In a decentralized state such as Sierra Leone, it is imperative that the new NMSSP 2019-2025 focus more on district-level implementation and capacity. This requires an Inception Phase whereby national and local stakeholders assist each district to develop budgeted, robust, comprehensive and costed District Operational Plans (DOPs) which are aligned with national plan. It is these DOPs that should then become the main basis for advancing and reviewing progress towards the overall NFNSIP’s objectives. d. The SUN Secretariat, with technical support from UNN REACH, has recently-completed a “Stakeholder Mapping”. This tool can serve as an excellent baseline for district-level gap identification in terms of who is doing what, where and when (the “4Ws”). A slight modification and 6-monthly updating of the Stakeholder Map together with using it in conjunction with the DOPs (with districts able to access it online) are all measures that will vastly improve district-level coordination, as well as monitoring, targeting and reporting efforts. It should be adapted and utilized routinely at district and central levels as a planning, resource tracking, mapping, gap identification, monitoring and reporting tool. e. Aid effectiveness and good governance practices in some countries have seen annual sectoral reviews based on performance indicators that are tracked at sub-national and national levels. Such an annual review is based on the principle of mutual accountability, whereby national and international stakeholders at all levels in a country become mutually accountable amongst one another and towards each other. The tools for such an annual review include a strong, transparent RMEF, district-level operational plans and an annual review meeting that brings all partners together to track, report on and support progress towards shared objectives. It is recommended that the new NMSSP benefit from such an annual review process in Sierra Leone. To increase district ownership, it is recommended that such annual sectoral reviews have the following six key features: i. Be led by all key ministers, mayors, district chiefs, district chairpersons and administrators ii. Occur during the dry seasons and be planned to take place over 3 full working days during a calendar time that avoids major agricultural, education, socio-cultural, political or public festivity events iii. Involve at least 3-months of planning to collect indicators, progress, challenges, facts and data that are compiled in an efficient, presentable and action-oriented manner during the review by relevant stakeholders iv. Serve as an opportunity for mutual accountability between the center and the periphery, between government ministries and departments, between government, parliament and civil society, between national and international stakeholders; v. Rotate annually so that it takes place in a different district each year, with priority being for districts that have demonstrated best progress on this strategic plan’s indicators. vi. Be documented in an Annual Review Report that encloses all presentations, captures all deliberations and summarizes actionable outcomes to track during each subsequent year. 37 | P a g e In conclusion, any strategic plan is only as strong as the structures which own, lead, manage, coordinate and implement it. It is therefore crucial that Sierra Leone establish improved management, planning, monitoring and evaluation structures at central and district levels in order to better coordinate between national and district level. Central and district bodies need inclusive platforms which enable them to achieve better results, as well as share, analyze and act upon relevant data and information. It is encouraging that during the introductory meeting held in April 2018 between the REACH UNN Heads of Agency and the newly-appointed Vice-President of Sierra Leone, the Government of Sierra Leone emphasized the need for intensifying inter-ministerial coordination through, among others, a more effective steering committee, a stronger technical committee and more focused parliamentary committee meetings overseeing nutrition and food security. Additionally, and recognizing the critical importance of downstream implementation challenges faced during the expired NFNSIP, the Government of Sierra Leone is now more determined to decentralize the coordination functions concerning nutrition and food security to the district levels, while ensuring that there is a mechanism to monitor the impact those coordination efforts at the district level. The attached Logical Framework, together with the Risk Management Framework will address some of above-mentioned critique. The recommended DOPs should adopt this Logical Framework and use the same parameters while spreading them across a timeframe with specific measurable outputs, responsibilities and results as well as reporting on progress each calendar quarter. 38 | P a g e XII. Risk Mitigation Framework As mentioned in the above sections, it is the responsibility of the SUN Secretariat and the Government of Sierra Leone to ensure that a risk register regularly updates the types of threats that might affect implementation and that good governance and effective risk management practices are followed to mitigate and report on risks. Some of the best principles of risk analysis are often developed and used by two key sectoral partners present in most countries: the large-scale private sector companies (particularly those involved in trade, banking, extractive industries, agribusiness operations, manufacturing and services, among others) as well as the military. While their business model and aims might differ, their analysis usually deploys almost all the key definitions, system-building elements, management mechanisms and mitigation tools needed for most strategic plans. Hence, they define risk by defining, calibrating, measuring and monitoring various types of threats, the likelihood and possible impact of these threats, identifying the most vulnerable aspects of their operations and accordingly developing risk prevention, preparedness and reduction strategies that mitigate the effect on their work. For the nutrition sector leadership, the risks, operations and impact are derived directly from the Conceptual Framework for Analyzing the Causes of Malnutrition and the matrix illustrating the interdependence of Nutrition-Specific, Nutrition- Sensitive and Enabling Environment actions (Figures 1 and 2 in the Situation Analysis chapter). Thus, a key part of engaging the private sector in Sierra Leone should therefore be for the nutrition sector to tap the risk management expertise and innovation used by national, international and joint-venture companies. Such a public private partnership would be an ideal way for these companies to apply their corporate social responsibility (CSR) in support of a key aspect necessary to sustain the lives, livelihood and welfare of Sierra Leonean consumers and clients. In this context, risk management is not a separate activity but is part of ensuring the enabling environment pillar is conducive for the changes sought through the nutrition-specific and nutrition-sensitive pillars underpinning this Strategic Plan in Sierra Leone. As such, the Risk Management Framework is a living document to be elaborated, reviewed and activated routinely by the governance, coordination and oversight bodies responsible for implementing this new Strategic Plan. Performing all the tasks and roles involved in managing these risks are neither new nor do they require commitment of additional resources. They merely require more effective ways of demonstrating the same types of full ownership, diligent responsibility and fiduciary control that are fundamental tenets in nutrition governance. The following matrix identifies the key risks threatening the successful implementation of this new Strategic Plan. It is adapted in most of its format and key elements from the AU’s ARNS 2015-2025 “Risk Analysis” Table, while tailored to suit Sierra Leone’s context. Further adaptation to elaborate additional types of risk analyses and mitigation measures, is not just possible but actually required. Hence, and once SUN Secretariat submits its annual work plan based on this new Strategic Plan to the Steering Committee for approval and once each District Administrator submits the District Operational Plan to the District Councils for approval, each of these work plans must contain an elaboration of this same Risk Mitigation Framework to a sufficient level of granularity that is suited for each of these work plans. 39 | P a g e Nutrition Security Risk Mitigation Framework 2019-2025 No. RISK CONSEQUENCES MITIGATION MEASURES LEAD RISK MANAGEMENT ROLE 1 Climate changes (e.g. droughts, floods, altered rainfall pattern etc.) accelerates negative impact on nutrition Implications will be on food & water access, food production (e.g. pests), transport, housing, services (e.g. disease epidemics), household food security & strained management capacity. District Operational Plans (DOPs) must include measures for natural disaster risk management as an integral component. Activate local and national disaster risk management responses; perform rapid vulnerability assessment, pre-stock and pre-position buffer food & medical supplies; adapt strategic plan elements to address new needs as part of a new subsidiary interim work plan; reprioritize target groups and accelerate interventions to mitigate effects on nutrition. District Administrators and SUN Secretariat, in close consultation with Sierra Leone’s Office of National Security (ONS; whose mandate is so support mitigation measures), District Councils, inter-ministerial and technical committees, Steering Committee as well as national and international partners involved in disaster risk reduction and response. 2 Civil and political strife (local/limited or national or cross- border/internat ional) War and insecurity will always pose threats to food and nutrition security among affected populations. Conversely, food insecurity may also lead to competition over scarce resources and, thus, precipitate conflicts. Carefully analyze and identify the role malnutrition is playing as a possible factor among the causes and/or among the result of a likely or actual civil/political conflict. Ensure that all local, national and international authorities involved in conflict resolution efforts are prioritizing nutritional support to all those affected. As for natural/climate disasters, activate local and national disaster risk management responses (e.g. rapid vulnerability assessment, pre-stocking/pre- positioning buffer food & medical supplies; adapt strategic plan to address new needs, develop interim work plan; reprioritize targets & accelerate interventions) District Administrators, District Councils, in close consultation with SUN Secretariat, Steering Committee as well as national and local law enforcement and government military leaders. 3 Insufficient prioritization of nutrition security in the national & district development plans and budget allocations Insufficient political will and/or resource allocation to support this strategy will result in a repeat of the failures seen in its predecessor where implementation stalled and nutrition indicators stagnated or deteriorated. Formulate & deliver targeted advocacy & political interventions with executive, legislative and local government to reaffirm commitment to nutrition through action. Emphasize that medium-long-term consequences of insufficient political willpower and resource allocation for nutrition include increased costs of morbidity and mortality, loss of productivity, weaker human capital, slower economic growth & potential political strife. Within the first 6 months of implementation, legislate to codify the nutrition security budgetary allocations and commitments into binding national law while also presenting these allocations, commitments and targets of the new strategic plan to the African Union/NEPAD’s Annual Peer Review Mechanism (APRM), the SUN Movement & the Independent Accountability Panel (IAP) of the Partnership for Maternal, Neonatal & Child Health (PMNCH) so that Sierra Leone elevates its status among African countries implementing continental and national commitments. Ministry of Finance and Economic Development to lead effort, in consultation with SUN Secretariat Parliamentary Network, Steering Committee, District Administrators & District Councils. Ministry of Foreign Affairs to consult with the Office of the President, Parliamentary Network, African Union Commission, NEPAD APRM, SUN & IAP/PMNCH in order to elevate the commitment of Government to nutrition security. 40 | P a g e No. RISK CONSEQUENCES MITIGATION MEASURES LEAD RISK MANAGEMENT ROLE 4 Adverse demographic and socio- economic developments outpace the ability to assure food and nutrition security A number of social transformations will affect food, health and care and thereby nutrition security. They include population growth, urbanization, migration, unemployment, exclusion, aging populations, etc. Ensure that similar social sector related strategic plans that cut across a number of sectors are subsumed under a social policy framework that enables cohesive implementation, integrated RCH services tracking the mutual effects each demographic and/or socio-economic development would have on the strategic plans (and on the overall social policy) and benefits from shared or coordinated governance and management structures that can address such effects and mitigate their impact on each strategic plan. For instance, this strategic plan should be subsumed under Sierra Leone’s emerging Social Protection Policy which could also serve as the overall umbrella for people living with HIV, people with special needs, gender, orphans, migrants and other prioritized target groups in the social policy. Steering Committee to work closely during 2018-2019 to avoid creating a separate policy framework for nutrition and, instead, work with relevant ministries and the World Bank so that the nutrition strategic plan is an integral subsidiary of an overall Social Protection Policy framework, alongside other relevant strategic plans. 5 Weak nutrition governance mechanisms result in poor implementation The multi-sectoral and complex nature of nutrition problems are fraught with challenges of responsibilities and accountabilities resulting in poor implementation and low achievement of objectives. Ensure sufficient attention to the structures and functions of all the management and coordination roles described in the new strategic plan’s governance elements, with particular attention to the smooth operation of the SUN Secretariat, the Steering Committee, the Technical Committee and the District Administrations as well as their respective structured accountability to national Parliament, Office of the President, District Councils in addition to their accountability to civil society and media bodies at both national and local levels. Ensure that annual work plans by the SUN Secretariat and District Administrators have measurable elements to track implementation, detect failing or deteriorating activities and results as well as to anticipate and plan to avert as many implementation challenges as possible, with clear escalation triggers to higher bodies and fully-documented reporting transparency about the issues and any progress made to resolve them. The new strategic plan, SUN Secretariat’s Annual Work Plan, District Operational Plans, Stakeholder Mapping, District and SUN Secretariat’s routine reporting on implementation progress and on management constraints as well all budget tracking reporting in relation to nutrition and food security should be posted online and updated monthly by a specific ITC officer (using software and hardware that SUN Secretariat can negotiate with Sierra Leone’s private sector companies as part of the latter’s corporate social responsibility) so that all this is publicly available to all citizens, civil society, media and stakeholder groups. Steering Committee in close consultation with District Councils will be the first bodies that will detect such weakness, particularly if they conduct in-depth quarterly reviews of implementation, management and coordination expected roles and capacity. Both Steering Committee and District Administrations should liaise closely with the Ministry of Local Government for governance weaknesses more relevant to the district and sub-district levels, while the Steering Committee must liaise with SUN Secretariat and the Parliamentary Network to resolve more central failures in governance. 41 | P a g e No. RISK CONSEQUENCES MITIGATION MEASURES LEAD RISK MANAGEMENT ROLE 6 Insufficient progress in nutrition- sensitive sectors, including agriculture, water supply & sanitation (WASH) as well as health sector interventions directly associated with nutrition such as reproductive, maternal, neonatal, adolescent health (RMNCAH) & communicable disease control Persistence of currently low levels of access to safe drinking water and adequate sanitation as well as weak progress in RMNCAH and disease control interventions will all represent a grave risk to the achievement of equitable and sustained progress in reducing malnutrition in Sierra Leone. Ensure that MOHS and other line ministries as well as district-level departments are directly engaged in nutrition governance and coordination efforts, with mutual updates on relevant sectoral interventions being shared and promptly acted upon. Advocacy efforts for nutrition, WASH, RMNCAH and communicable disease control resources and implementation support should highlight the synergies in- between these interventions are well-understood and addressed. Information sharing, joint field missions, mutual sharing of monitoring reports, mutual participation in key milestones (workshops, substantive reviews, mid- term reviews, assessments, evaluations, etc) should be the norm. Within MOHS, close inter-departmental coordination through task forces and seamless collaboration between FND, sanitation, RMNCAH departments and personnel should be expected, encouraged and used in staff performance accountabilities. Steering Committee needs to be in constant proactive advocacy in order to reinforce these synergies and interdependencies, in close consultation with District Councils, MOHS, Ministry of Local Government, Ministry of Finance and Economic Development and others. UNN-REACH constituent partners need to ensure that WASH, RMNCAH and disease control interventions (including NTDs) are closely harmonized amongst one another in order to strengthen alignment to the governmental efforts mentioned above. 42 | P a g e XIII. Summary Budget by Objective (in US Dollars) Component Type Strategic Objectives (SO) & Intermediate Result (IR) Strategic Directions & Priority Activities 3132 Component Cost & Component % of Budget Total33 7/2019 – 6/2020 7/2020- 6/2021 7/2021- 6/2022 7/2022- 6/2023 7/2023- 6/2024 7/2024- 6/202534 Nutrition Specific SO1: By 2025, to reduce the prevalence of stunted children under 5 years (U5C) to 25% from 2017/18 baseline levels. SO2: By 2025, to reduce the prevalence of wasting children under 5 years (U5C) to less than 5% from 2017/18 baseline levels. SO3: By 2025, to reduce by 20% the prevalence of iodine &vitamin A deficiencies in U5C, adolescents, PLW35 & WRA from 2017/18 baseline levels. SD 1: Intensify promotion of optimal care practices affecting nutritionally- vulnerable groups SD 2: Strengthen health and community development systems to ensure a holistic and responsive delivery of services in conducive and safe environments SD3: Improve household food security especially households with multiple overlapping factors influencing their food security SD 4: Rapidly increase access to adequate nutrition among target groups by leveraging existing efficient education and social sector service delivery platforms 161,533,352 40 % 32,306,670 32,306,670 32,306,670 24,230,002 24,230,002 16,153,335 Nutrition Sensitive 161,533,352 40 % 32,306,670 32,306,670 32,306,670 24,230,002 24,230,002 16,153,335 Nutrition Governance IR: To create an enabling environment for central & district multi-sectoral coordination and action SD5: Prioritize action to strengthen district capacity in nutrition: SD6: Urgently undertake legislative, governance and executive actions to create the necessary enabling environment in support of multi- sectoral nutrition 80,766,676 20 % 16,153,335 16,153,335 16,153,335 12,115,001 12,115,001 8,076,667 Budget Total (Yearly % of Total) 403,833,380 100% 80,766,676 20% 80,766,676 20% 80,766,676 20% 60,575,005 15% 60,575,005 15% 40,383,337 10% 31 Abbreviations: U5C = Children under 5 years of age; PLW = Pregnant or Lactating Women; 32 Activities under each of these Strategic Directions will be inserted in Draft 2.0 33 Due to rounding, there may be insignificant variance between component budget totals and yearly allocations. 34 6th year suggested by stakeholders at Final Validation Workshop. Costs accordingly redistributed across 6 years, compared to previous 5-year budget formats in early drafts. 35 PLW = Pregnant or Lactating Women; WRA = Women of reproductive age 15-49 years; U5C = Children under 5 years of age 43 XIV. Annexes Annex 1 List of References Annex 2 Overview of Sierra Leone’s Decentralized Administrative and Health Systems Annex 3 Findings of the Review of Progress Achieved in NFNSIP 2013-2017 Annex 4 Nutrition Governance Frameworks used in the NFNSIP 2013-2017 Annex 5 Data Validation Workshop Agenda February 2018 Annex 6 Data Validation Workshop’s Summary Report March 2018 Annex 7 Consultative Stakeholder Workshop Summary December 2017 Annex 8 Logical Framework Annex 9 Costing Methods & Optional Formats for “Summary Budget by Objective” Annex 10 Process Milestones in the Review and Update of NFNSIP 2013-2017 44 Annex 1: List of References36 1. World Development Indicators: Health gaps by income: Demography, Reproductive and women's health, Child health, Health systems, Global goals: ending poverty and improving lives, Women in development, Global goals: promoting sustainability. World Bank Group. Updated 01/03/2017. Online table at http://wdi.worldbank.org/table/ 2. Recommendations on Wheat and Maize Flour Fortification Meeting Report: Interim Consensus Statement, WHO, 2009. 3. Sierra Leone Malaria Indicator Survey 2016. National Malaria Control Programme (NMCP) [Sierra Leone], Statistics Sierra Leone, University of Sierra Leone, Catholic Relief Services, and ICF. 2016. Sierra Leone: NMCP, SSL, CRS, and ICF. Sierra Leone, 2016. 4. Annual Health Sector Performance Report 2016, Ministry of Health and Sanitation (MOHS), 2016. 5. Quarterly Nutrition Surveillance Report , Quarter 2--- Apr1- Jun 30 2016, Ministry of Health and Sanitation (MOHS), Directorate of Food and Nutrition (DFN), 08/2016. 6. Harmonized Framework for identifying risk areas and vulnerable populations in the Sahel and West Africa, Ministry of Agriculture, Forestry and Food Security (MAFFS), Sierra Leone, 10/2016. 7. Lactation Duration and Progression to Diabetes in Women Across the Childbearing Years: The30-Year CARDIA Study. By Erica P. Gunderson et al. JAMA Internal Medicine. doi:10.1001/jamainternmed.2017.7978. Published online 01/2018. 8. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Christopher G. Owen et al. Downloaded 01/2018 from www.ajcn.nutrition.org 9. Multi-sectoral Nutrition Overview (MNO). REACH. Sierra Leone, 01/2018. 10. Aid Policy, Government of Sierra Leone. 2010. 11. National Food and Nutrition Security Policy 2012-2016. Ministry of Health and Sanitation (MOHS). 2012. 12. Sierra Leone National Nutrition Survey 2017 (SLNNS 2017), Ministry of Health and Sanitation (MOHS) and Action Against Hunger (AAH). 01/2018. 13. Tracking Government Expenditure on Nutrition in Sierra Leone. Scaling Up Nutrition (SUN) Secretariat and Action Against Hunger (AAH). 2017. 14. Aggregated Costing Tool. REACH. 2016. 15. SIERRA LEONE Call for Commitments for Nutrition. Scaling Up Nutrition (SUN). 04/2013. 16. Sierra Leone MQ SUN Costing Mission, Country visit report. J. Keylock and M. Swor. 03/2013. 17. Food and Nutrition Security Business Working Group in Sierra Leone. Draft Concept Note, 12/2017 18. Policy and Plan Overview - Sierra Leone. Government of Sierra Leone, SUN Secretariat, REACH. 11/2017. 19. National Social Protection Policy, Version 8.0. Government of Sierra Leone. 02/2011. 20. National Social Protection Strategy and Implementation Plan 2013- 2018. Government of Sierra Leone. 2012. 21. Sierra Leone Nutrition and Food Security Stakeholder Mapping. REACH and SUN. Draft Version of 01/2018. 22. (Ebola) Recovery and Transition Priorities in Sierra Leone (Draft). April 2015. 23. Proactive community case management and child survival in peri-urban Mali. Johnson AD, Thiero O, Whidden C, et al. BMJ Glob Health 2018;3:e000634. doi:10.1136/bmjgh-2017-000634 24. Indicators for assessing infant and young child feeding practices: Part 3: Country profiles. WHO. 2010. 25. Indicators for assessing infant and young child feeding practices. Part 2: Measurement. WHO. 2010. 26. Gender Equality and Women’s Empowerment in Fragile and Conflict-Affected Situations: A Review of Donor Support. OECD Development Policy Papers. No. 8. 10/2017. 36 Some references were cited without further details by reviewers and stakeholders who contributed to the data in this document. http://wdi.worldbank.org/table/ http://www.ajcn.nutrition.org/ 45 27. Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher– Lancet Commission. www.thelancet.com Published online May 9, 2018 http://dx.doi.org/10.1016/S0140-6736(18)30293-9 28. Early Nutrition and its Later Consequences: New Opportunities: Perinatal Programming of Adult Health -EC Supported Research. Volume 569. Edited by B. Koletzko P. Dodd, H. Akerblom and M. Ashwell. In Advances in Experimental Medicine and Biology, Volume 569. Springer. 2005. 29. National Food and Nutrition Security Implementation Plan 2013-2017. Government of Sierra Leone. 2013. 30. Food for Thought: An Independent Assessment of the International Code of Marketing of Breast-milk Substitutes. Angela Evans/Breastfeeding Innovations Team. 03/2018. 31. National Strategic Master Plan for elimination of Neglected Tropical Diseases 2016-2020. Ministry of Health and Sanitation (MOHS). 2016. 32. Minimum Standards for Child Protection in Humanitarian Action. 2012. Full version available at http://cpwg.net/wp-content/uploads/2012/10/Minimum-standardsfor-child-protection-in- humanitarian-action.pdf 33. Reaching the Global Target to Reduce Stunting: How Much Will it Cost and How Can We Pay for it? World Bank Group, Results for Development, Children’s Investment Fund Foundation, 1000 Days and Bill & Melinda Gates Foundation. 2017. 34. Working with SUN countries to (a) Cost actions to improve nutrition and (b) mobilize the required resources: Preliminary findings from 16 Countries. SUN Movement Secretariat. 03/2013. 35. Morbidity, mortality, and long-term consequences associated with diarrhoea from Cryptosporidium infection in children younger than 5 years: a meta-analyses study. Ibrahim A. Khalil et al in The Lancet Global Health. Volume 6. Accessed through www.thelancet.com/lancetgh 07/2018. 36. Global Strategy for Women’s, Children’s and adolescents’ health (2016–2030) 2018 monitoring report: Current status and strategic priorities. Special theme: Early childhood development. WHO. 2018. 37. Sierra Leone Social Protection Assessment. Report No. 78195-SL. Human Development Department Social Protection Unit Africa Region. World Bank Group. 06/2013. 38. Sierra Leone Child Poverty Report. Government of Sierra Leone. 2016. 39. An Investment Framework for Meeting the Global Nutrition Target for Stunting. Shekar, Meera, Jakub Kakietek, Julia Dayton Eberwein, Jon Kweku Akuoku, Audrey Pereira, and Mary D’Alimonte.. Washington, DC: World Bank Group. 2017. 40. Sierra Leone National Anemia Strategy. Ministry of Health and Sanitation (MOHS). 2017. 41. Sierra Leone RMNCAH Implementation Plan. Ministry of Health and Sanitation (MOHS). 2017. 42. Review of Agriculture Related Policies in Sierra Leone. Zommers Z. PhD and Chand A PhD. FAO, 01/2018. 43. Tanzania Joint Nutrition Support Program/UNICEF 1990; in African Regional Nutrition Strategy 2015- 2025, Africa Union Commission, July 2016. 44. Lancet Series on Maternal and Child Nutrition 2013, cited in Africa Regional Nutrition Strategy 2015- 2025, African Union Commission, Department of Social Affairs, 06/2016. 45. IYCN Barrier Analysis, Western Area, HKI Report, 2013 46. The Way Ahead 2016-17 Annual Report. http://www.familyplanning2020.org/entities/96 (accessed June 17, 2018) 47. National Micronutrient Survey. Ministry of Health and Sanitation (MOHS). 2014. 48. State of Food Security in Sierra Leone 2015 – Comprehensive Food Security and Vulnerability Analysis (data collected September-October 2015). This is a joint publication by the Government of Sierra Leone, WFP, FAO, AfDB, EU & WB. 49. Anemia, micronutrient deficiencies, and malaria in children and women in Sierra Leone. Wirth JP, Rohner F, Woodruff BA, Chiwile F, Yankson H, Koroma AS, Russel F, et al. PLoS ONE 11(5): e0155031. doi:10.1371/journal.pone.0155031 50. Wirth JP, Ansumana R, Woodruff BA, Koroma AS, Hodges MH, Association between sickle cell and β- thalassemia genes and hemoglobin concentration and anemia in children and non-pregnant women in Sierra Leone. BMC Research Notes (2018) 11:43 https://doi.org/10.1186/s13104-018-3143-x http://dx.doi.org/10.1016/S0140-6736(18)30293-9 http://cpwg.net/wp-content/uploads/2012/10/Minimum-standardsfor-child-protection-in-humanitarian-action.pdf http://cpwg.net/wp-content/uploads/2012/10/Minimum-standardsfor-child-protection-in-humanitarian-action.pdf http://www.thelancet.com/lancetgh http://www.familyplanning2020.org/entities/96 https://doi.org/10.1186/s13104-018-3143-x 46 51. Control of soil-transmitted helminths in school age children in Sierra Leone after a decade of preventive chemotherapy intervention. Bah YB, Bah MS, Paye J, Conteh A, et al. Infectious Diseases of Poverty. In press. (2018) 52. Schistosomiasis in school age children in Sierra Leone after six years of mass drug administration with praziquantel, Bah YB, Bah MS, Paye J, Conteh A, et al. Frontiers in Public Health. In press. 2018. 53. Children without worms and STH survey report. National NTDP. Ministry of Health and Sanitation (MOHS). All age. 2018. 54. African Health Strategy 2016-2030, African Union Commission, Department of Social Affairs, 05/2016. 55. African Regional Nutrition Strategy 2015-2025, African Union Commission, Department of Social Affairs. 2015. 56. Malabo Declaration on Accelerated Agricultural Growth &Transformation for Shared Prosperity & Improved Livelihoods, African Union Commission, Malabo, Equatorial Guinea, 06/2014. 57. MOHS-UNICEF Sierra Leone 2017 REPORT. 58. WFP PLHIV/TB and OVCs nutritional surveillance status analysis 2012 (Western Areas statistics) 59. MoHS TB program assessment (2009) 60. National NTDP survey 2016 61. National Anemia prevention and Control Strategy. 62. MOHS April 2017 MCHW 63. MOHS SLDHS 2008 and SMART 2010 64. MOHS DHS 2013 65. During consultations and validation of this report, stakeholders observed that most of the anemia in Sierra Leone is not due to iron deficiency. 66. MOHS SLMS 2013 67. Sierra Leone Micronutrient Survey, 2013 68. MOHS reported that this is no longer a target group starting with the 2013 SLMS 69. Sierra Leone SMART Survey. 2010. 47 Annex 2: Overview of Sierra Leone’s Decentralized Administrative & Health Systems37 Areas and Districts Sierra Leone is divided into four major areas, namely Northern Region, Southern Region, Eastern Region and the Western Area where the capital Freetown is located. The regions are further divided into 16 districts: (seven in the north, four in the south, three in the east and two in the Western Area), which are in turn sub-divided into chiefdoms, governed by local paramount chiefs. Chiefdoms There are 160 chiefdoms in 16 districts (North, North West, East and South) governed by local paramount chiefs and 31 zones in the Western Area. Chiefdoms are further divided into sections and sections into villages. In the 16 districts, there are approximately 14,413 villages and communities and the average village has a population between 100-500 inhabitants, headed by local chiefs. In the Western Area, the rapidly growing non-rural communities merge into each other and are administered by a mixture of councilors and traditional leaders. With the recent devolution of social services to local communities, the country has been divided into 19 local councils that have been further sub-divided into 392 wards. Each ward is headed by an elected councilor. Community Structure Each village is headed by a chief supported by the council of elders, including religious leaders bounded by cultural norms and traditions. They meet regularly to discuss issues relating to the development of their communities including health, agriculture, and education. The village authorities play important roles in health activities such as social mobilization, selection and motivation of community workers. Community workers used to include drug distributors (CDDs), traditional birth attendants (TBAs) and others, but some have been replaced or assimilated by a community health worker (CHW) cadre. So in addition to nutrition, communities and their CHWs are also involved in delivering and promoting other health interventions such as insecticide treated bed nets (ITN), home management of malaria as well as expanded program for immunization (EPI) and reproductive and child health RCH program interventions. The village composition is usually stable except for villages that are located in border areas where there is continuous movement due to trade and kinship relations across international borders. Health Service Delivery Organization The health care service delivery organization system is based on the primary health care concept, which was started in the 1980s. The public health delivery system comprises of three levels: (a) peripheral health units (community health centers, community health posts, and maternal and child health posts) for first line primary health care; (b) district hospitals for secondary care; and (c) regional/national hospitals for tertiary care. In Sierra Leone’s current post-Ebola recovery period, meeting the demand for effective and efficient health care service delivery is a particularly critical challenge for the Ministry of Health and Sanitation (MOHS). General accessibility to health facilities shows considerable district variations. Qualitative perceptions from rural communities reveal that physical distance to health facilities, staffing/attitude of staff, effective supply chains and economic factors present major barrier in accessing health care services. In addition, social roles, expectations, norms and values of behavior make women more vulnerable to ill health; yet they have fewer resources and opportunities to protect their health or to utilize health care. The existing functional health facilities are inadequate and inequitably distributed within chiefdoms and districts. To address this situation, MoHS has adopted a number of strategies. For instance, and in collaboration with its partners, MOHS is building new facilities and rehabilitating existing ones in order to increase access and improve service utilization. Education positively affects health seeking behavior and economic empowerment, thus the increase in school enrolments is an opportunity that will enhance utilization of health services. Equally, the enactment of the child rights and gender bills will encourage beneficiaries to timely seek health care services. Similarly, the MoHS is encouraging continuous integration of 37 Adapted from Government of Sierra Leone, Ministry of Health and Sanitation, Master Plan for Neglected Tropical Diseases Elimination in Sierra Leone 2016-2020. Pages 13-23. 48 health services as a strategy to increase utilization of services and reduce missed opportunities at service delivery points (primary, secondary and tertiary). At each District level, there is a District Health Management Team (DHMT) headed by a District Medical Officer (DMO). The DMO supervises all district-level public health staff and also coordinates all public health activities within the district. The DMO is also responsible for administration, planning, support supervision, training, monitoring and evaluation and research, among other roles. The DHMT has focal persons for each disease Program. With the devolution of primary and secondary health care to local councils, leadership and governance of the health sector is the primary role of the MoHS, both within the health care system and in relation to other actors whose activities impact on health. This includes the private as well as the public sector in order to enhance access and improve health outcomes. Health financing The Government of Sierra Leone (GOSL) allocates budgets to line ministries, including MoHS, annually. Development partners (e.g. bilateral and multi-lateral agencies, Global Fund for AIDS, Tuberculosis and Malaria, GAVI) and international philanthropic organizations (including faith-based bodies) were funding approximately 50% of the annual health budget as of 2016. A number of UN agencies also provide support to the MoHS in thematic areas, such as reproductive health, malaria, HIV/AIDS, nutrition and policy development. However, inadequate financing remains the primary constraint inhibiting the full implementation of the health sector annual work plans (AWP). Mostly only 30% of the approved Ministry’s budget is actually disbursed Health workforce: There are critical shortages of most cadres of Health Care Work force. Staff vacancies at primary, secondary and tertiary health care delivery levels are affecting utilization and quality of service delivery. Inadequate manpower and staff attrition are issues that are being addressed by increased training and recruitment into the health sector. Inadequate human resources to implement health and nutrition interventions continue to be a concern, particularly at the district and sub-district levels in Sierra Leone. Basic health worker necessities and amenities such as transportation, accommodation and remuneration are improving. There had been an increase in the number of institutional training facilities for Maternal and Child Health (MCH) Aides and State-Enrolled Community Health Nurses (SECHNs) at district level to increase the number of staff in the Peripheral Health Units (PHUs). Furthermore, Community Health Officers (CHOs), Environmental Health officers (EHOs) and other cadres are trained at the School of Community Health Sciences of Njala University (Bo Campus). In addition, mechanisms are being put in place to attract qualified Sierra Leonean nationals in the diaspora and international staff to fill in the human resource gaps. 49 Annex 3: Findings of the Review of Progress Achieved in NFNSIP 2013-2017 A. Summary Status of Acute Malnutrition & Stunting at the end of 2017: Figure 9.1: Trends in levels of acute malnutrition (WHZ<-2 and/or oedema) in Sierra Leone38 SSA – Sub Saharan Africa WCA – Western and Central Africa 38 Source: SMART Nov 2017 Report. Figure title should exclude the word “acute” since stunting indicates chronic malnutrition. 2008, GAM, 10.5 2008, Underweight, 21.3 2008, Stunting, 37.4 2010, GAM, 6.9 2010, Underweight, 18.7 2010, Stunting, 34.1 2014, GAM, 4.7 2014, Underweight, 12.9 2014, Stunting, 28.8 2017, GAM, 5.1 2017, Underweight, 13.1 2017, Stunting, 31.3 SSA, GAM, 9.0 SSA, Underweight, 21.0 SSA, Stunting, 38.0 WCA, GAM, 11.0 WCA, Underweight, 22.0 WCA, Stunting, 37.0 M a ln u tr it io n ( % ) Fig 9.1 Trends in levels of acute malnutrition (WHZ<-2 or oedema, WHO 2006) in Sierra Leone) 2008 2010 2014 2017 SSA WCA 50 Table 8.15: Prevalence of National, Moderate & Severe Underweight in Children (6-59 months) based on WAZ Scores by District39 Province District Global Underweight (WAZ<-2) Moderate Underweight (- 3≤WAZ≤-2) Severe Underweight (WAZ<-3) N n % 95% CI n % 95% CI n % 95% CI Western Urban 721 90 12.5 9.9-15.6 78 10.8 8.6-13.6 12 1.7 1.0-2.7 Slums 605 94 15.5 12.7-18.9 79 13.1 10.4-16.2 15 2.5 1.2-5.0 Rural 613 66 10.8 8.3-13.8 45 7.3 5.1-10.4 21 3.4 2.2-5.3 Eastern Kono 732 99 13.5 11.0-16.6 75 10.2 8.3-12.6 24 3.3 2.2-4.9 Kenema 630 99 15.7 12.3-19.8 74 11.7 9.0-15.2 25 4.0 2.4-6.5 Kailahun 532 67 12.6 9.7-16.1 49 9.2 6.8-12.3 18 3.4 2.0-5.7 Southern Pujehun 648 109 16.8 13.3-21.0 84 13.0 9.7-17.2 25 3.9 2.3-6.3 Bo 529 76 14.4 10.5-19.4 53 10.0 7.2-13.8 23 4.3 2.5-7.3 Moyamba 562 65 11.6 9.4-14.1 51 9.1 7.2-11.4 14 2.5 1.6-4.0 Bonthe 558 62 11.1 7.8-15.6 50 9.0 5.9-13.3 12 2.2 1.2-3.9 Northern Kambia 515 68 13.2 9.7-17.8 59 11.5 8.4-15.4 9 1.7 0.8-3.6 Port Loko 517 63 12.2 9.3-15.8 49 9.5 7.2-12.4 14 2.7 1.6-4.6 Koinadugu 631 84 13.3 10.5-16.7 63 10.0 7.5-13.2 21 3.3 2.1-5.2 Tonkololi 652 98 15.0 11.9-18.7 71 10.9 8.5-13.9 27 4.1 2.7-6.2 Bombali 539 81 15.0 11.5-19.3 66 12.2 9.6-15.5 15 2.8 1.6-4.9 National 8,984 1,221 13.6 12.8-14.5 964 10.5 9.8-11.3 275 3.1 2.7-3.5 Table 8.19: Prevalence of National, Moderate and Severe Stunting in Children (6-59 months) based on HAZ Scores by District40 Province District Global Stunting (HAZ<-2) Moderate Stunting (-3≤HAZ≤- 2) Severe Stunting (HAZ<-3) N n % 95% CI n % 95% CI n % 95% CI Western Urban 721 166 23.0 19.9-26.5 110 15.6 13.4-18.0 56 7.8 5.8-10.3 Slums 605 165 27.3 22.8-32.3 114 19.2 15.5-23.4 51 8.4 5.9-11.8 Rural 607 176 29.0 24.6-33.8 120 20.7 16.9-25.1 56 9.2 7.3-11.5 Eastern Kono 730 224 30.7 26.6-35.2 147 20.8 18.1-23.8 77 10.5 8.0-13.8 Kenema 631 221 35.0 29.1-41.5 146 23.9 19.7-28.7 75 11.9 8.7-16.0 Kailahun 530 183 34.5 29.8-39.6 131 25.5 21.6-30.0 52 9.8 7.2-13.2 Southern Pujehun 646 250 38.7 34.1-43.6 172 27.5 23.8-31.5 78 12.1 9.2-15.7 Bo 527 169 32.1 26.7-38.0 116 22.5 18.0-27.8 53 10.1 7.4-13.5 Moyamba 561 197 35.1 30.5-40.0 127 22.8 19.6-26.4 70 12.5 9.5-16.3 Bonthe 558 175 31.4 26.5-36.6 133 24.2 19.9-29.0 42 7.5 5.4-10.4 Northern Kambia 514 169 32.9 26.9-39.5 128 25.3 20.9-30.2 41 8.0 5.5-11.4 Port Loko 519 144 27.7 21.4-35.1 97 19.4 14.9-24.9 47 9.1 6.0-13.4 Koinadugu 627 196 31.3 26.3-36.7 124 20.5 16.7-24.9 72 11.5 8.9-14.6 Tonkololi 646 195 30.2 25.9-34.9 132 20.9 17.2-25.1 63 9.8 7.6-12.4 Bombali 539 173 32.1 27.7-36.8 113 21.1 17.4-25.4 60 11.1 7.9-15.5 National 8,961 2,803 31.3 30.0-32.6 1,910 21.3 20.3-22.3 893 10.0 9.2-10.7 39 Source: SMART November 2017 40 Ibid. 51 B. Food Production, Consumption and Accessibility: (Source: Ministry of Agriculture, Forestry and Fisheries, March 2018) Projected food Crop Production41 Crop Baseline 2017 (Mt) Projected 2018 (Mt) Achieved by 2017[1] Rice Paddy 897,069 966,662.12 To be determined by end of 2017/2018 cropping season Cassava 2,476,118 2,580,912 Sweet potato 153,188 27,618 Ground nut 20,128 158,171 Food production and accessibility indicators Description Baseline 2017 Target 2018 Achieved by 2018 Indicator Food consumption score (Population Target) Poor 19.9% Borderline 33.5% Acceptable 46.5% Poor <5% Borderline <15% Acceptable >50% Poor 18.0% Borderline 45.7% Acceptable 36.2% Food diversity score (number of food groups consumed by households) Group 1-2 (severely food insecure) =13.9% *Group 3 (Moderately Food insecure) =18.8% *Group 4 (marginally Food insecure) =24.6% *> Group 4 (Food secure) = 43.2% (Source: CFSVA) Group 1-2 (severely food insecure) =5% *Group 3 (Moderately Food insecure) =15% *Group 4 (marginally Food insecure) =20% *> Group 4 (Food secure) =>20% *Group 1-2 (severely food insecure) =6.9% *Group 3 (Moderately Food insecure) =17.9% *Group 4 (marginally Food insecure) =28.8% *> Group 4 (Food secure) = 46.4% Coverage % of farmers receiving training and accessing inputs 55% estimate 80% 67% % of Mother Support Groups receiving training and accessing inputs N/A 80% 98% 42 (Trainings) MOH- UNICEF ANNUAL REPORTS 2017) Target group Farming households, Mother Support Groups Cash for work and food for work indicators Description Baseline 2016/17 Target 2018 Achieved by 2018 Indicator Household (HH) expenditure on food HH Food Expenditure = 59 % (CFSVA) HH Food Expenditure= 30% (CFSVA) < 50 =19.5% (Pop) 50 = 35.3%(Pop) 65-75 =24.8% (pop) >75% = 20.4% Food consumption score Poor 19.9% Borderline 33.5% Acceptable 46.5% Poor <5% Borderline <15% Acceptable >50% Poor 18.0% Borderline 45.7% Acceptable 36.2% Coverage Proportion of HH receiving cash for work 3% 6% N/A Proportion of HH receiving food for work 20% 40% N/A Target group Vulnerable Households 41 2017 production figures are provisional (indicative). Ideally calculation of crop production figures is not based on fiscal year (Jan - Dec). Rather, the production figures are based on production season (from the September2017 harvest until in January/February/March 2018, representing one production cycle). This means 2017 harvesting of some crops (especially lowland rice) has just ended. (Double-cropping of rice, groundnut and long duration of rice variety). MAFF is currently preparing to calculate the actual production figures based on field reports (yield study and area measurement conducted by MAF staff nationwide), an exercise whose outcome will then represent the final result for 2017. It is possible that the final result could be higher than the baseline (2011) or otherwise. This is because crop production level is not always linear growth because of factors which include crop failure due to climate change, flooding, human disaster, crop variety, farming methods etc. Additionally, Sierra Leone’s 2015/16/17 crop production levels represent the recovery period from the Ebola shocks since the 2014/15 production season. 42 Food & Nutrition Directorate, Ministry of Health and Sanitation (MOHS) https://mail.yahoo.com/?soc src=mail&soc trk=ma# ftn1 52 C. Nutrition & Nutrition-Relevant Health Outcomes and Coverage: Overall Nutrition Indicator Targets for NFNSIP 2013-2017 Indicator Baseline in 2013 Target by 2017 Achieved by 2018 Stunting 34.1% 28.5% 31.3% Underweight 18.7% 13.1% 13.6% Wasting 6.9% 4.8% 5.1% Overweight 8% 5.6% 18.4% (Obesity 7.5%)43 Child mortality 140/1000 live births 98/1000 live births 120/1000 live births44 Indicators and coverage for SAM & GAM45 Description Baseline 2013 Target 2017 Achieved by 2018 Indicator SAM prevalence among children 6-59 months 1% 0.2% 1.0% GAM prevalence among children 6-59 months 6.9% 4.8% 5.1% Coverage IMAM coverage 12% 50% 58 %46 Target group SAM and MAM Children Indicators and coverage for Low birth weight and underweight Description Baseline 2013 Target 2017 Achieved by 2018 Indicator Incidence of low birth weight 11% 5% 7 % SLDHS 2013 Prevalence of underweight among children <2 years 40.9% 13.1% 13.6% Coverage Malnourished PLWs, all pregnant teenagers, women with multiple births, pregnant PMTCT women on SFP47 N/A 80% MALNOURISHED PLWs on supplementary feeding - 18,410 of 54, 204 (%) 34% WFP REPORT 2017 PL Teenagers on SFP 7 % (5779/ 87000) WFP REPORT 2017 WOMEN ON MULTIPLE BIRTH ON SFP (%) No estimation PG ON PMTCT (%) 45% (1633/3600) NACP DATA PLWs in districts with stunting rates >40% receiving blanket feeding 0% 80% N/A Under 2s in districts with stunting rates >40% receiving blanket feeding 0% 80% N/A Primary schools’ children in the school feeding program 33% 50% N/A Target group PLWs &<2s in high districts with high stunting rates, malnourished PLWs, Pregnant teenagers, women with multiple births, Pregnant women on PMTCT, school going girls 43 SMART Nov 2017 indicates 2.3% prevalence of overweight among children aged 6-59 months. 44 UN 2015, as indicated in MOHS National Health Sector Performance Report 45 SAM = Severe Acute Malnutrition. MAM = Moderate Acute Malnutrition. GAM = Global Acute Malnutrition. 46 Sia Manyeh, Food & Nutrition Directorate, Ministry of Health and Sanitation (MOHS) 47 SFP = Supplementary Feeding Program 53 Indicators and coverage for early initiation of breastfeeding Description Baseline 2014 Target 2018 Achieved by 2018 Indicator Early initiation of breastfeeding– (immediately within one hour of birth) 45% 60% 56.8% Coverage Health Facilities (District Hospitals and Bemoans Centres) compliant with Baby Friendly Hospital/Community Initiative (BFHI) N/A 50% N/A Target group Pregnant women Indicators and coverage for exclusive breastfeeding (EFB) Description Baseline 2013 Target 2017 Achieved by 2018 Indicator Percent of Infants 0-5 months exclusively breastfed 32% 60% 61.6% Coverage Pregnant and lactating women reached with EBF promotion >50% 80% 76% MOHS – UNICEF 2017 REPORT48 Target group Pregnant and lactating women, husbands, grandmothers Indicators and coverage for complementary feeding Description Baseline 2013 Target 2017 Achieved by 2018 Indicator % Children 6-23 months old with minimum acceptable diet 19% 40% 29.7% (Min Dietary Diversity) & 44.1%49 (Min Meal Frequency) % of children with timely initiation of semi/solid foods at 6 months 51% 60% 55.2% SLNNS 2017 Coverage Estimated number of PLW receiving Complementary feeding promotion messages >50% 80% 76% 50 Target group Pregnant and lactating women, husbands, caretakers, grandmothers 48 Data is only from 11 DISTRICTS; MOHS reported that no data was available from Bothe and Western AREA ) as there are there are no implementing partners in these districts 49 SMART Nov 2017: 29.7% for Minimum Dietary Diversity & 44.1% for Minimum Meal Frequency 50 MOHS-UNICEF 2017 REPORT 54 Indicators and coverage for Vitamin A Supplementation (VAS) Description Baseline 2013 Target 2017 Achieved by 2018 Indicator % of children < 5 years with Vit A deficiency 28% 20% 17.4% Coverage % of children 6-59 months receiving VAS during mass campaign 91% 98% 101 %-51 % of children 6-59 months receiving VAS (routine) 38% 80% 35% HMIS 2016 % of children 6-23 months old consuming Vitamin A rich fruits and vegetables 66.9% SLDHS 2010 80% 41.7% SLDHS 2013 – ADJUSTED % of postpartum mothers receiving VAS 40% 52 80% 76.9%53 Target group children 6-59 months old, post-partum women Indicators and coverage for Iron & Folate Supplementation (IFA)54 Description Baseline 2013 Target 2017 Achieved by 2018 Indicator % of children 6-59 months with anaemia 76% 51% 76.3% SLMS % of women 15-49 years with anaemia 45% 36% 44.8% (non-preg) 70.0% (preg)55 Coverage % of children (6-23 months) old who consume iron rich foods 59% 80% 61.8 % SLNNS 2017 % of women who took IFA (iron or folic acid was captured in SLMS- combined iron folate) supplement during pregnancy for 90 days or more 44% 60% 65.8% SLMS 2013 Target group Pregnant women, Women 15-49 years Indicators and coverage for Iodine Description Baseline 2013 Target 2017 Achieved by 2018 Indicator % of school aged children with low urinary iodine (less than 100 µg/l) 34%56 20% N/A 57 Coverage % of households consuming adequately iodised salts 63% 80% 80.7% SLMS 2013 Target group Households Indicators and coverage for Zinc Supplementation Description Baseline 201358 Target 2017 Achieved by 2018 Indicator Prevalence of stunting among children <5 years 34% 23.9% 31.3% Coverage % of children <5 receiving zinc in ORT for diarrhoea treatment 6.1% 80% 88% (SLDHIS 2) Target group Children under <5 years 51 MOHS April 2017 MCHW 52 MOHS SLDHS 2008 and SMART 2010 53 MOHS DHS 2013 54 During consultations and validation of this report, stakeholders observed that most of the anemia in Sierra Leone is not due to iron deficiency. 55 MOHS SLMS 2013 56 Sierra Leone Micronutrient Survey, 2013 57 MOHS reported that this is no longer a target group starting with the 2013 SLMS 58 Source: SMART 2010 55 Indicators and coverage for nutritional mitigation for PLHIV/TB and OVCs59 Description Baseline 2013 Target 2017 Achieved by 2018 Indicators Prevalence of malnourished PLHIV 44%60 20% 45% OVCs 5-18 years food insecure 50% (WFP est.) 25% 49 % Prevalence of malnutrition among TB patients 40%61 80% 32% Coverage Malnourished PLHIV, TB, OVCs receiving nutrition support 9.8% (PLHIV) 10% (TB) <5% (OVCs) 65% 40% 50% 100% 100% 41% WFP FIGURES PLHIV children 0-2 years receiving nutrition support TBD 80% 100% Target group Malnourished PLHIV, TB patients, OVCs, Entire Population Indicators and coverage for deworming Description Baseline 2013 Target 2017 Achieved by 2018 Indicator % of children <5 infected with Soil Transmitted Helminths 54% 20% 20%62 % of pregnant women who take intestinal parasite drugs 36% 60% 72.4% DHS 2013 % of children 12-59 months de-wormed two times a year 85.8% 95% 96%- April 2017 MCHW -MOHS administrative data % of children 12-59 months de-wormed two times/year (routine) 18% 60% 69.1%) SLNNS % of primary school age children taking intestinal parasite drugs in school (5-11 years old). (percentage calculation requires total school children but in absolute 1,985,618 numbers children aged 5- 15 years were dewormed in 2017) - Source MOHS NTD Program. TBD 80% 101% Source MOHS NTD Program. Target group Pregnant women, children 6-59 months old, primary school going children Indicators and coverage for Insecticide Treated Nets (LLIN) distribution Description Baseline 2014 Target 2018 Achieved by 2018 Indicator Malaria prevalence among children under five years 25% 13% 40% (Source: MIS) SLMIS 2016 Coverage % of pregnant women utilising ITNs 28% 80% 44% (Source: MIS) SLMIS 2016 Children under five years sleeping under a bed net 30% 80% 44 % SLMIS 2016 Target group Pregnant women and children under five years Indicators and coverage Intermittent Prevention Treatment of Pregnant Women (IPTp) Description Baseline 2013 Target 2017 Achieved by 2018 Indicator Prevalence of anaemia among pregnant women 62% 32%63 70 % SLMS 2013 Coverage Women following correct IPTp during pregnancy 41% 90% 71% IPTP2 (SLMIS –Page 27)31 % IPTP3 (SLMIS 2016 Page 27) Target group Pregnant women 59 PLHIV = People Living with HIV. TB = Tuberculosis. OVC = Orphans and Vulnerable Children. 60 WFP PLHIV/TB and OVCs nutritional surveillance status analysis 2012 (Western Areas statistics) 61 MoHS TB program assessment (2009) 62 National NTDP survey 2016 63 National Anemia prevention and Control Strategy 56 Indicators and coverage of Household water treatment Description Baseline 2013 Target 2017 Achieved by 2018 Indicator Coverage HH using adequate water treatment methods 2% 80% 5.5% Household access to improved water source 54% 74% 61.8% (CFSVA;2015)64 Target group Households Indicators and coverage for hand washing with soap and water and sanitation Description Baseline 2013 Target 2017 Achieved by 2018 Indicator Prevalence of diarrhoea among children <5 11% 7.15% 6.3% Coverage Evidence of hand washing with soap 13% 50% 72.0 Access to improved sanitation facility 40% 66% 15.6% (CFSVA 2015)65 Safe disposal of baby faeces 54% 80% N/A Target group Households, School Children Indicators and coverage for family planning Description Baseline 2013 Target 2017 Achieved by 2018 Indicators Average age at first pregnancy among women 20-49 (years) 19 20 N/A Median number of months since preceding birth 36.2 36 N/A Coverage % of women who use modern contraceptive methods 16.6% 25% 23% 2017 based on MOHS service data estimate FPET % of young people 10-24 years receiving family planning & counselling messages TBD 80% N/A Target group Women of reproductive age, school going girls/boys, adult men Indicators and coverage for NCDs66 Description Baseline 2013 Target 2017 Achieved by 2018 Indicators Prevalence of overweight and obesity in women 17.9% 6% 25.9% (overweight=18.4 % and obese=7.5% ) SLNNS 2017 Prevalence of NCDs (diabetes, hypertension, coronary heart disease) TBD TBD N/A – steps survey to be conducted next year Coverage Population reached with healthy lifestyles messages TBD 80% 0.14 % MOHS DFN Report from clinical Nutritionist Target group Entire Population Indicators and coverage for food safety and hygiene Description Baseline 2013 Target 2017 Achieved by 2018 Indicator Prevalence of diarrhoea among children under five 11% 7% 6.3% SLNNS 2017 % of population tested and confirmed to be affected by food borne diseases N/A Reduce by 25% N/A Coverage % of vendors registered, trained and certified N/A 80% N/A % of food processors & vendors observing food safety & hygiene practices N/A 60% N/A Target group Street vendors, school children, food processors, food transporters, market women, households 64 State of Food Security in Sierra Leone 2015 – Comprehensive Food Security and Vulnerability Analysis (data collected September-October 2015). A joint publication of Government of Sierra Leone, WFP, FAO, AfDB, EU & WB. 65 Ibid. Urban access to improved sanitation was 43.9% while rural access was only 4.3%. 66 NCDs = Non-Communicable Diseases 57 Annex 4: Nutrition Governance Frameworks used in the NFNSIP 2013- 2017 Figure 1: Linkages between the National coordination mechanisms Figure 2: District food and nutrition security coordination Structure Table 4: Governance structures at the Community level Unit Leadership Governance body Responsibility Ward Ward Councillor (Democratic structure) Ward Committee (5 men, 5 women) • Political representation of the community • Articulate and prioritise community needs for planning Chiefdo m Paramount Chief (Traditional structure) Chiefdom Development Committee • Traditional leadership • Resource allocation • Custodian of cultural and traditional norms Village Town Chief Village/Area/Health Development Committee • Manage community development interventions 58 ANNEX 5: Data Validation Workshop Agenda February 2018 TECHNICAL WORKING GROUP FOR THE REVISION & UPDATE OF SIERRA LEONE’S NATIONAL FOOD AND NUTRTION SECURITY IMPLEMENTATION PLAN (NFNSIP) FOR 2019-2025 Venue: FAO Country Office, Freetown, Sierra Leone, Monday 26 February 2018 67 MC = Master of Ceremonies 68 Guidance to include purpose, format, instructions about breaks and break-out groups and discussion rules. 69 RNF = UNN REACH National Facilitator, Dr Philip Kanu 70 IC = UNN REACH International Consultant for Review and Update of NFNSIP, Dr Akram Eltom TIME ACTIVITY PARTICIPATION EXPECTED RESULTS MODERATOR 9:00-9:05 AM Prayers RNF67 9:05-9:25 AM Self-introductions ALL RNF 9:25-9:30 AM Welcome Statement TWG Chair RNF 9:30-9:40 AM Workshop Guidance68 RNF69 IC 9:40-10:10 AM • Presentation of Findings & • Participants divide voluntarily into 3 parallel Breakout Groups (BGs): BG1: Summary Situation Analysis (SITAN) BG2: Objectives and Strategic Directions (SOSD) BG3: Results, Monitoring & Evaluation Framework (RMEF) IC70 Workshop participants subdivided into 3 breakout groups, with discussion method, room allocation and expectations clarified. RNF 10:10-10:25 AM Coffee-Tea Break & All participants move to their respective BGs rooms ALL BGs seated in their respective rooms RNF & IC 10:25-10:30 AM Each BG selects 1 Discussion Moderator & 1 Rapportuer BG members Moderators & Rapporteurs selected RNF & IC 10:30-11:40 AM Each BG discusses & produces expected results & hand it on flash disc to RNF BG members 3 BG outputs documented RNF 11:40 AM-12:10 PM 10-minutes each plenary presentation by each BG Moderator of results BG Moderator BG outputs presented in plenary RNF 12:10-12:40 PM 30 minutes Initial Plenary discussion on all BG results ALL IC 12:40-13:30 PM Lunch Break ALL 13:30-14:15 PM 45 minutes Final Plenary discussion to agree on all BG results ALL Approved New NFNSIP Situation Analysis, Objectives, Strategic Directions & RMEF IC 14:15-14:45 PM Plenary Discussion and agreement on Name/Title of NFNSIP ALL Approved New NFNSIP name & title RNF 14:45-15:15 PM Plenary Discussion and Agreement on format of NFNSIP ALL Approved New NFNSIP format & structure IC 15:15 -15:30 Presentation of Summary Workshop Outcomes & Endorsement ALL Endorsed Workshop recommendations IC 15:30-15:45 PM Closing Remarks TWG Chair RNF 4:00 PM End of Workshop 59 Annex 6: Data Validation Workshop Report March 2018 REVISION & UPDATE OF SIERRA LEONE’S NATIONAL FOOD AND NUTRTION SECURITY IMPLEMENTATION PLAN (NFNSIP) FOR 2019-2025 Summary Report on the Outcomes of the Data Validation Workshop Report Date: 15 March 2018 (Final Submitted 18 April 2018) I. Key Workshop Outcomes: ➢ Data gaps and errors were addressed to better inform the NFNSIP revision and update ➢ Options for the new NFNSIP’s title, objectives and strategic directions were better defined ➢ Proposed format and structure were approved ➢ Proposed results monitoring and evaluation framework (RMEF) was, modified and approved II. Workshop Context: The United Nations Network (UNN)/ Renewed Efforts Against Child Hunger and undernutrition (REACH) initiative was re-launched in Sierra Leone in early 2017 to provide technical and financial support to the Scaling up Nutrition (SUN) Secretariat in the Office of the Vice President. REACH is providing support to the Government of Sierra Leone on nutrition governance through the SUN Secretariat following the approved Country Implementation Plan (CIP) of the UNN and the Government of Sierra Leone. A key activity in the CIP is the revision of the expired National Food and Nutrition Security Implementation Plan 2013-2017. Since 8 November 2017, UNN/REACH recruited an International Consultant to provide the technical support in the review process. Extensive stakeholders’ consultative meetings were conducted between December 2017 and February 2018 in order to initiate the process in December 2017. Full involvement and ownership of all key stakeholders and partners remains key in the review and update process. Moreover, the creation in January 2018 of a Technical Working Group (TWG) was critical and useful in providing oversight to the review and update process. Focused on reviewing and validating most metrics and key elements of the new NFNSIP for 2019-2025, this Data Validation Workshop was the first of two such events. As soon as the newly-elected government and parliament both take office, the second and final Full Validation Workshop will be held to approve the first draft of the new NFNSIP. Following the TWG’s approval of its agenda and invitation of participants, the Data Validation Workshop was held from 9 AM until 4 PM on Monday 26 February 2018 at the FAO Country Office Conference Room in Freetown. III. Workshop Objectives, Inputs & Process: The workshop was very well attended, with over 80 participants representing all relevant development sectors, all types of institutions (public, private, UN, donor and civil society) and all levels in Sierra Leone (central level as well as district representatives). Of particular note was the active participation by Sierra Leone’s Parliament Clerks, Ministry of Foreign Affairs, Ministry of Finance and Economic Planning as well as academic/research institutions and the private sector. 60 The list of participants who attended is attached as Annex II to this Report. (to be inserted). The five presentations below were prepared by the UNN/REACH Consultant and shared with all participants before and during the event. The objective of the Data Validation Workshop was to review, discuss, adjust and approve the new NFNSIP’s title, format, situation analysis, objectives and strategic directions. The attached Agenda for the Workshop (Annex I) had also been approved by the TWG and was shared with the participants prior to the Workshop. Invited participants and all district stakeholders met during the Consultations were also given the opportunity to share any further comments they wish to make on the expired NFNSIP 2013-2017 and to propose options by email before the Workshop on the new NFNSIP’s title/name options, format/structure as well as its objectives and strategic directions. 1. Summary Situation Analysis 2. New NFNSIP title/name options 3. New NFNSIP format and structure 4. New NFNSIP Population Targets, Objectives and Strategic Directions 5. New NFNSIP format for Results, Monitoring & Evaluation Framework (RMEF) The meeting was opened by the Chairperson of the UNN/REACH in Sierra Leone, Dr. Hamid Elbashir (UNICEF Country Representative in Sierra Leone), and it was chaired by the National Coordinator of the SUN (Scaling-Up Nutrition) Movement Secretariat in Sierra Leone, Dr. Mohamed Foh. The Consultant presented the above-handouts and outlined the expected process and outcomes from the Workshop. Rather than having three breakout groups (BGs in the attached Agenda), it was decided that the Situation Analysis will be discussed immediately in plenary mode, following which only two BGs will focus on the Consultant’s handouts on Objectives and Strategic Directions (BG 1) and the Results, Monitoring and Evaluation Framework (RMEF; BG 2). Each BG’s rapporteur then presented in plenary the main outputs from their deliberations and, following their modification/additions in plenary, the rapporteurs’ modifications of the Consultant’s handouts (see Annex IV) were shared with the UNN/REACH National Facilitator, Dr. Philip Kanu for compilation and sharing with the UNN/REACH Consultant. The Workshop ended with a request by the Chairperson for all missing data to be provided to the Consultant by latest 1st March 2018 in order to enable the Consultant to develop Draft 1 of the new NFNSIP before the end of March. However, the national elections and its run-off meant that some data is still missing and that the submission of this Workshop Report and the new NFNSIP will be slightly delayed as a result. IV. Workshop Outcomes and Recommendations: 1. Summary Situation Analysis Workshop participants provided the changes and data updates to the presented handout prepared by the Consultant. Attached as Annex III is the consolidated input made by participants into the Draft Situation Analysis (before, during and after the Workshop) to improve the evidence-base and data for the new NFNSIP’s. 2. New NFNSIP title/name options Workshop participants narrowed down the options for new NFNSIP’s title/name to approximately 6 versions which were as follows. Taking all the excellent suggestions by stakeholders into consideration, the recommended name/title of the new NFNSIP which best reflects the consensus is as follows: “Multi-sector Strategic Plan to Reduce Malnutrition in Sierra Leone 2018 – 2023” 3. New NFNSIP format and structure Workshop participants approved the following recommended format/structure and size considerations for the new NFNSIP: a. Total size: Not to exceed a maximum of 30 pages, excluding annexes. b. Structure: (The estimated maximum page limit for each section is in parentheses): i. Table of contents (1 page) ii. List of Acronyms (1 page) iii. Forward (1 page) iv. Acknowledgements (1 page) v. Executive Summary (2 pages) vi. Introduction (2 pages) 61 vii. Review Methodology (1 page) viii. Situation Analysis : (4 pages) • Country Situation Overview • Nutrition Conceptual Framework • Policy Overview • Multi-Sectoral Nutrition Situation Analysis ix. Lessons & Opportunities (3 pages) x. Strategic Priorities : (10 pages) • Key Target Populations • Goal • Objectives • Strategic Directions • Priority Interventions xi. Results, M & E Framework (2 pages) xii. Risks Mitigation Framework (1 page) xiii. Summary Budget by Objective (1 page) xiv. Annexes (5 pages) 4. New NFNSIP Population Targets, Objectives and Strategic Directions Workshop participants narrowed down the options for new NFNSIP’s population targets, objectives and strategic directions to the following recommended elements: a. Priority Target Populations: In the new NFNSIP 2019-2025, it is recommended that these should include: • Newborns, • Children under 5 years of age, • Adolescents, • Women of reproductive age, • Persons with special needs (including people living with HIV or TB, mentally or physically-challenged persons, orphans and vulnerable children and others) • returnees, • Internally displaced persons (IDPs), • People living with HIV or TB, • Urban poor and • Female heads of households • Victims of natural and man-made disasters b. Proposed Goal for the new NFNSIP 2019-2025: Based on stakeholders’ consultations, and taking into account the considerations in the Road Map, the following overarching Goal is recommended for the new NFNSIP: “To contribute to the African Union’s Africa Regional Nutrition Strategy (2015-2025), the UN Sustainable Development Goals by 2030 and the UN Global Strategy for Maternal, Newborn, Child and Adolescent Health (2016-2030) by accelerating and scaling-up nutrition action across all sectors in Sierra Leone” c. Recommended Strategic Objectives (SOs) & Strategic Directions (SDs) in the new NFNSIP 2019-2025:71 • Strategic Objectives (SOs): SO1: To reduce by 20% the number of stunted & by 50% the number of underweight U5C72 . SO2: To reduce by 30% the prevalence of micronutrient deficiencies in U5C, PLW73 & women 15–45 of age. SO3: To create an enabling environment for central & district multi-sectoral coordination and action • Strategic Directions (SDs): 71 The baseline for all objectives is at the end of 2017 or by mid-2018 and the achievement horizon is by end of 2023. 72 U5C = Children under 5 years of age. 73 PLW = Pregnant or Lactating Women 62 NUTRITION-SPECIFIC STRATEGIC DIRECTIONS: SD 1: Intensify promotion of optimal care practices affecting nutritionally-vulnerable groups ➢ Based on existing and new operations research, determine key factors (barriers and enablers) affecting maternal, infant and young child feeding and care practices (including sanitation and hygiene practices) then develop and apply an appropriate social behavior change and communication (SBCC) strategy & plan to address these factors ➢ Improve delivery of holistic baby and child friendly services at all levels (including early childhood development programs such as parenting program) ➢ Improve the nutritional status through appropriate feeding practices of children under the age of 5 years, pregnant and lactating women and women of reproductive age (15-49); with a particular prioritization of initiation of breastfeeding within 1 hour of birth, exclusive breast feeding for the first 6 months and appropriate complementary feeding practices from locally available ingredients thereafter. ➢ Strengthen preventive measures against nutrition related diseases; ➢ Improve access to quality curative nutrition services; • SD 2: Strengthen health and community development systems to ensure a holistic and responsive delivery of services in conducive and safe environments ➢ Intensify programs focused on preventing diseases affecting children, adolescents & women ➢ Timely and comprehensive management of illnesses affecting children and women ➢ Increase access to quality ante-natal care, intrapartum and post-partum care, including breast-feeding counseling, newborn health and immunization for mother and child ➢ Scale-up and rapidly expand IMNCI74 ➢ Scale up the transition from of campaign-based vitamin A supplementation and deworming among children under-five to integrated routine-based reproductive and child health services at the six monthly point of contact ➢ NUTRITION-SENSITIVE STRATEGIC DIRECTIONS: • SD3: Improve household food security especially of households with multiple overlapping factors influencing their food security status ➢ Improve household food security situation (quantity, quality and safety) in order to satisfy the daily dietary needs of the population; ➢ Strengthen crop, food diversification, and bio-diversification initiatives ➢ Scale-up appropriate technologies to improve food quality & quantity (eg fortification) ➢ Promote suitable food preservation, storage and preparation methods • SD 4: Rapidly increase access to adequate nutrition among target groups by leveraging existing efficient education and social sector service delivery platforms ➢ Improve the coverage and quality of education including access to education of girls ➢ Expand and intensify school feeding for all children and adolescents ➢ Scale–up and support school gardens, in collaboration with the private sector in each district ➢ Utilize the new Social Protection Framework to ensure cash-based incentives for education of children and adolescents (particularly girls) ➢ Scale-up establishment & maintenance of quality WASH structures and systems at all levels ENABLING ENVIRONMENT STRATEGIC DIRECTIONS: • SD5: Prioritize action to strengthen district capacity in nutrition: ➢ Identify districts which are food-insecure75 and 50% of other districts experiencing worst acute malnutrition and stunting levels. ➢ Deliver focused sustained support to these districts in order to significantly strengthen their capacity to manage, coordinate, develop and deliver integrated, multi-sectoral, multi-stakeholder, nutrition-specific & nutrition-sensitive interventions involving at least health, agriculture, education, water, sanitation, gender/labor/social welfare sectors. 74 Integrated Management of Child and Newborn Illnesses 75 Based on the regular Ministry of Agriculture, Fisheries and Forestry monitoring supported by the UN’s World Food Program in Sierra Leone. 63 • SD6: Urgently undertake legislative, governance and executive actions to create the necessary enabling environment in support of multi-sectoral nutrition ➢ Adapt the new NFNSIP 2019-2025 to the emerging social protection policy and framework; ➢ Advocate for the development and/or strengthen the coherence of policies and legislation affecting food and nutrition (e.g. Legislation Regulation of the Marketing of Breastmilk Substitutes, National Policy on Salt Iodization, etc) ➢ Consistently emphasize, explicitly-reference and incorporate clear accountabilities for nutrition within other sectoral and inter-sectoral policies and strategic frameworks/plans (particularly in health, agriculture, food security, livelihoods, water supply, sanitation, education, etc) ➢ Foster effective coordination mechanisms which effectively engage and mobilize multiple sectors (e.g. water supply and sanitation, agriculture, food security/livelihoods, education, health, social protection, etc.) and multiple stakeholders (civil society, development partners, government, private sector) actors in those coordination mechanisms. ➢ Increase the magnitude and transparency of domestic resource mobilization, allocation and disbursement for the effective and efficient delivery of nutrition-related services ➢ Significantly increase and incorporate transparent accountabilities for flow and utilization of domestic financial and non-financial resources in support of nutrition ➢ Improve evidence generation and utilization at national and district level for informed advocacy, planning and intervention actions supporting nutrition ➢ Increasing the role of district councils, parliament, the media and civil society across all development sectors in monitoring progress towards nutrition advocacy goals & objectives; ➢ Increase commitment from policymakers, policy advisors, and multi-sectoral programme designers at national district and sub-district levels to accord food and nutrition security (F&NS) a high priority in the political and national development agenda: ➢ Orient new parliamentary members, while identifying and engaging F&NS champions through the parliamentary network; ➢ Ensure the all F&NS (SUN) focal persons within EACH Ministry meet at least quarterly with an emphasis on sustainability and seniority of focal persons; ➢ Mainstream the new ‘overarching’ multi-sectoral social sector policies so that the new F&NS strategy is an integral part of the social development and social protection policy framework (alongside other social strategies such as those dealing with food security, disability, HIV, etc) during the first 6 months of implementation; ➢ Develop a Cabinet paper on F&NS; (2 months), presented to Cabinet by a ‘lead’ Minister, sent to law officers (1 month), forwarded to legislature committee (1 month), laid before Parliament, debated and passed (1 month); ➢ Legislate the necessary parliamentary F&NS acts by December 2018; ➢ Ensure budget lines within each Ministry are dedicated to F&NS by July 2018; ➢ Ensure MoHS-Directorate of F&NS has its own account code; ➢ Enforce the legal framework to ensure an ‘enabling environment’ from 2019 onwards ➢ Intensify gender sensitization at all levels 5. New NFNSIP Results Monitoring & Evaluation Framework Nutrition governance, aid effectiveness principles (especially mutual accountability and transparency) and a robust, results management framework are critical if harmonized efforts of development partners are expected to align with a cohesive, integrated and well-managed strategic implementation plan. The NFNSIP is not intended to be a source of fresh financing streams for national commitments to fight malnutrition. Rather, it is a catalytic framework and process whereby national and subnational leadership can better design, adopt, integrate, scale-up, coordinate and manage their own commitments, actions and resource investments aimed at achieving better nutrition and development outcomes. As such, the workshop recommended that the new NFNSIP 2019-2025 should have the following 8 features: 1. The design of the new NFNSIP as well as its RMEF should be much simpler and more concise, enabling better results-based management and greater transparency as well as accountability. It must account for emergencies, contingencies, resource constraints, human resource capacity (especially at district level) and the necessary measures to mitigate shocks that affect human and financial resource availability during implementation and monitoring. Indicators should be SMART (specific, measureable, appropriate, realistic and time-bound); as well as linked with regional (Africa-wide) and global indicators (eg SDGs and EWEC) for comparability. 64 2. A Problem Tree and Theory of Change in the new NFNSIP should be show how nutrition-sensitive, nutrition- specific and enabling environment factors interact, together with a Result Monitoring and Evaluation Framework (RFEF). 3. In a decentralized state such as Sierra Leone, it is imperative that the new NFNSIP 2019-2025 focus more on district-level implementation and capacity. This requires an Inception Phase (reflected in the RMEF; preferably June-December 2018) whereby national and local stakeholders assist each district to develop budgeted, robust, comprehensive and costed District Operational Plans (DOPs) which are aligned with national plan. It is these DOPs that should then become the main basis for advancing and reviewing progress towards the overall NFNSIP’s objectives. 4. The SUN Secretariat, with technical support from UNN REACH, has recently-completed a “Stakeholder Mapping”. This tool can serve as an excellent baseline for district-level gap identification in terms of who is doing what, where and when (the “4Ws”). A slight modification and 6-monthly updating of the Stakeholder Map together with using it in conjunction with the DOPs (with districts able to access it online) are all measures that will vastly improve district-level coordination, as well as monitoring, targeting and reporting efforts. 5. Aid effectiveness and good governance practices in some countries have seen annual sectoral reviews based on performance indicators that are tracked at sub-national and national levels. Such an annual review is based on the principle of mutual accountability, whereby national and international stakeholders at all levels in a country become mutually accountable amongst one another and towards each other. The tools for such an annual review include a strong, transparent RMEF, district-level operational plans and an annual review meeting that brings all partners together to track, report on and support progress towards shared objectives. It is recommended that the new NFNSIP benefit from such an annual review process in Sierra Leone. 6. The following draft design for an RMEF is recommended in order to address some of above-mentioned critique. The recommended DOPs should use the same parameters but spread them across a timeframe with specific measurable outputs at the end of each calendar quarter. 7. Even a good RMEF or a well-designed strategic plan are only as strong as the structures that own, lead, manage, coordinate and implement them. It is therefore crucial that Sierra Leone establish improved management, planning, monitoring and evaluation structures at central and district levels in order to better coordinate between national and district level. Central and district bodies need inclusive platforms which enable them to achieve better results, as well as share, analyze and act upon relevant data and information. 8. The following RMEF matrix is recommended for the new NFNSIP: 76 Key to Indicator Definition & Methods/Units of Measurement: Plan Parameter Indicator76 & Means of Verification Annual Target for 2019-2025 Responsibilities: Specify Lead Stakeholder & Support Stakeholder(s) Budget & Funding Source Assumption s Risks & Risk Mitigation Measures IMPACT: OUTCOME: OUTPUT 1: Activity 1.1 OUTPUT 2: Activity 2.1 65 (Post-script: Following the Data Validation Workshop, the TWG requested the development of a Logical Framework was developed which largely replaces the purposes of the above-mentioned RMEF table. 66 Annex 7: Consultative Stakeholder Workshop Summary 7 December 2017 The name of the new strategic implementation plan has to be more focused on what we intend to achieve through the plan- it was agreed the name should be changed. We must have 13 technical working group (TWG) members who will be reviewing (in a timely manner) the materials which the consultant will be sharing through the UN Network/UN REACH National Facilitator. Representatives of the TWG will be drawn from organizations that will have time to carry out the review. We should have a broader group for validation purpose of the product. The consultation has to be broadened to capture all stakeholders in the areas of food and nutrition security, health, wash, social protection, HIV/AIDS. Expiring NFNSIP 2013-2017 (soft copy) should be shared to all partners particularly the TWG. 67 Annex 8: Logical Framework 68 GOAL: To contribute to the African Union’s Africa Regional Nutrition Strategy (2015-2025), the UN Sustainable Development Goals by 2030 and the UN Global Strategy for Maternal, Newborn, Child and Adolescent Health (2016-2030) by accelerating and scaling-up nutrition action across all sectors in Sierra Leone Strategic Objective 1: To reduce the prevalence of stunted children under 5 years of age (U5C) to 25% from 2017/18 baseline levels Strategic Objective 2: To reduce the prevalence of wasting in children under 5 years of age (U5C) to less than 5% from 2017/18 baseline levels Strategic Objective 3: To reduce by 20% the prevalence of iodine and vitamin A deficiencies in U5C, adolescents, PLW77 & WRA from 2017/18 baseline levels Interventions78 Activity (inputs) Target Population Performance indicators (Outputs) Target indicators by 2023 (Outcomes) 1.1 Improve pre- conception nutrition • Nutrition awareness in schools, colleges, civil society, parliamentarians • Avoidance of short birth intervals • Non-pregnant adolescents • Non-pregnant WRA • Underweight (BMI <18.5) in non- pregnant WRA decreases from 5% • Overweight (BMI >25) and obesity (BMI >30) in non-pregnant WRA decreases from 18% and 8% respectively 1.2 Maternal dietary supplementati on • Screening of PW in ANC • Supplementation of Pregnant Women (PW) with MUAC (<23 cm) • Pregnant women • Routine monitoring of MUAC (<23 cm) in ANCs and supplementation coverage • PW taking deworming in ANC increase from 72% to 95% • Reduction of PW with MUAC (<23 cm) from 6% in 2017 to 3% • Reduce LBW from 7% in 2013 to 5% 1.3 Multiple micro-nutrient Supplementation (MMS)/ fortification • Improve ANC service delivery • Improve supply chain management to ANC • Review policy on iron folic acid (IFA) versus MMS • Ensure mandatory fortification standards on flour, oil, salt • PW • Health workers in ANCs • Supply chain managers • Importers of salt • SL Standard Bureau • PW receiving 90 days + of IFA (or MMS) increase from 66% in 2013 to 90% • Households consuming adequately iodised salts increase from 81% in 2013 to 95% • Mothers receiving post-partum VAS from 77% to 95% • Reduction of Hb<10gm/dl in PW from 42% in 2013 to 21% • Reduction of folate deficiency in PW from 70.0% to 35% Increase coverage of routine VAS in children 6-59 months from 35% in 2016 to 80% 77 PLW = Pregnant or Lactating Women; WRA = Women of reproductive age 15-49 years; U5C = Children under 5 years of age 78 While preserving the Logical Framework to focus on the more direct accountabilities within nutrition, sufficient linkages to RMNCAH and WASH have been made in pages 29 and 30 of the Strategic Objectives chapter as well as in the 6th Risk Category of the Risk Management Framework table. 69 1.4 Breastfeeding (BF) • Improve ANC counselling • Improve PNC counselling, including counselling on IYCF and early stimulation (for 0-23 month olds) • Ensure all District Hospitals and BEmONC are compliant with Baby Friendly Hospital • Improve social awareness and support for Lactating Women (LW) • All PW • Lactating mothers • Infants 0-6 months • Children 7-23 months • Health Workers • Public • Mothers initiating breastfeeding within 1 hour of birth • Mothers receiving EBF messages increase from 76% to 95% • Mothers of 0-23 month olds receiving messages on IYCF and early stimulation • Increase of BF within 1 hour of delivery from 57% in 2017 to 95% • EBF to 6 months of age increase from 62% in 2017 to 75% • Mothers continuing to breast feed to increase from 95% by 12 months of age 2017 to 95% by 23 months of age • % of mothers engage 0-23 month olds in early stimulation activities, 30% 1.5 Complementary feeding (CF) • Improve counselling & food preparation demonstration • Improve social awareness and support for mothers of young children by MSGs and other civil society groups • Families including partners, in- laws, community leaders • Children 6-23 months of age • Health workers • PLW, partners, in-laws and community leaders receiving CF promotion messages increase from 76% (PLW only) to 95% each group • Increase of timely initiation of CF from 55% in 2017 to 95% • Increase of minimum dietary diversity from 30% to 50% and of minimum meal frequency from 44% to 60% 1.6 Dietary supplementation for children • Screening (for MAM) and supply for dietary supplements • School feeding programs • Children 6-59 months • Children 5-14 years • Percentage of districts providing IMAM and dietary supplementation • IMAM coverage increases from 58% of PHUs to 80% • Decrease in MAM cases from 4% in 2017 to 3% • Increase primary school feeding from 24% of schools to 80%, including pre- primary school classes 1.7 Dietary diversification • Awareness raising at all levels • Encourage production and consumption of diverse crops by farmers and in backyard gardens • Increase access to markets • All age groups • Farmers • Households • Traders • Children 6-23 months consuming VA- rich foods increase from 42% to 80% • Children 6-23 months consuming iron- rich foods increase from 62% to 80% • VAD decrease in VAD from 17% in U5C to 12% • Increase diversity scores by HHs by 50% compared to 2017/18 baseline 1.8 Feeding behaviours and stimulation • Promotion of dietary diversity and health lifestyle messages • Promoting early stimulation and early learning messages among parents, other caregivers, and health and nutrition service providers • PLW, lactating mothers & families, partners, in- laws, community leaders • CHW, PHU, clinic/hospital staff • Increase in dietary diversity and health lifestyle messages to 95% of all groups • Parents and other caregivers receiving messages on early stimulation, provided by health and nutrition health service providers 95% • Reduction of overweight among children from 18% to 9% and obesity from 7.5% and 4% • % of mothers, fathers, and other adult caregivers engage 0-59 month olds in early stimulation and early learning activities, 30%, 20% & 50% 70 1.9 Treatment of SAM • Screening (for SAM) and supply of dietary supplements • Children 6-59 months • Percentage of districts providing dietary supplementation (for SAM) • Reduced for 1.1% in 2017 to 0.6% 1.10 Disease prevention and management • Use of ITNs • Intermittent preventive treatment during pregnancy (IPTp) and infancy (IPTi) • Increase access to quality ANC, intra- and post-partum care, including EBF counseling, newborn health and immunization for mother and child • Hand washing with soap at 5 key points • Scale-up and rapidly expand timely, appropriate management of neonatal, childhood illnesses (IMNCI) • Annual deworming of 6-59 months and SAC • PMTCT (HIV) and nutrition • PLW with TB and nutrition • ANC • PHUs and outreach • CU5 • School-aged children (SAC) • PW • PW and CU5 utilising ITNs increases from 44% to 80% • PW receiving at least 3 doses of IPTp increases from 31% to 80% • Percentage of infants receiving at least 3 doses of IPTi • Percentage of U5C receiving zinc in ORT for diarrhoea treatment increase from 88% in 2018 to 95% • Deworming of 6-59 months and SAC remains high (69% and 77% in 2017) • Malaria in CU5 decrease from 40% in 2016 to 35% • Anaemia in CU5 (Hb<10gm/dl) in decreases from 51% to 25% • Malaria in PW from % to % • Anaemia (Hb <11g/dl) in WRA decreases from 21% in 2013 to 10% • Anaemia in PW (Hb<10gm/dl) decreases from 42% to 21% • Diarrhoea among CU5 decrease from 6% to 4% • STH prevalence in SAC remains low (<20%) 1.11 Nutrition in Emergencies • Contingency planning at national and district levels • GoSL-national • District councils • Donors • UN and NGO partners • Community leaders • National and district contingency plans for climate change (e.g. floods mudslide, droughts), insecurity (internally displaced or refugees) and/or epidemic (e.g. Ebola, Cholera) challenges • National plan and focal point persons • District plans and focal point person 71 INTERMEDIATE RESULT: To create an enabling environment for central & district multi-sectoral coordination and action Interventions Activity (inputs) Target Population Performance indicators (Outputs) Target indicators by 2023 (Outcomes) 3.1 Food Security • Advocate for local content in public health interventions • Implement the Food Safety Act • Provision of training inputs to Mother Support Groups (MSGs), Farmer Based Organisations (FBOs) and Agricultural Business Centres (ABCs), SL Chamber of Agri-business Development (SLeCAD) • Policies and financial resources (loans, grants) for small and medium enterprises (SMEs) • Parliamentarians, GoSL • Public • UN agencies • MSGs • FBOs • Private Sectors • SLeCAD • ABCs • SMEs • National Farmers Federation ( NaFFSL) • Increase nutrition-sensitive agriculture by 50% • Increase production of OFSP, yellow cassava, moringa, legumes, pumpkins • Increase production of rice from 1.3 to 2million tons • Increase production of cassava from 3.3 to 5 million tons • Increase production of sweet potatoes (including OFSP) from 187,000 to 1 million tons • Increase production of groundnut from 73,000 to 500,000 tons • Household expenditure on food reduce from 59% of income to 45% • Household food consumption score increase from 53.7 to • Household dietary diversity score increase from 5.3 (of 12) to 8 • Acceptable food consumption scores increase from 47% to 75% • Increase market share for local producers and processors of easy-to- use complementary foods from ~20% to 80% • Appropriate use and composition of home-made complementary foods • Increase production and consumption of local commodities 3.2 Social safety nets • Adapt the new NFNSIP 2019-2025 to and subsume it as an integral part of the emerging national social protection policy and framework as well as the National Child Welfare Policy along with strategies on other cross- sectoral strategies such as those for HIV and AIDS, gender, disaster risk management, disability etc. • Supplementary feeding programs (SFPs) • Food vouchers for OVC • Cash transfers for OVC • PLHIV • TB • OVCs • Malnourished PLW • All pregnant teenagers • Women with multiple births • Maintain SFP coverage of 100% for PLHIV/TB and HIV children 0-2 years • Increase SFP, food vouchers, cash transfer coverage increase from 41% to 100% for OVCs • Increase SFP, to 100% for malnourished PLW (from 34%), pregnant teenagers (from 7%), women with multiple births and PMTCT from 45% to 100% • Prevalence of malnourished PLHIV reduce from 45% to 30% • Prevalence of malnourished TB reduce from 32% to 25% • Reduce LBW from 7% in 2013 to 5% 3.3 Early child development (ECD) • ECD feeding programs • Create awareness about benefits of ECD • Develop community-based ECD targeting marginalized communities • Adoption of Free of Charge (FOC) universal primary education • Ministry of Social welfare, Gender and Children’s Affairs (MoSWGCA) • Public • Community leaders • Minimum ECD standards developed and training teachers and caregivers. • Strengthen ECD teaching certification to ensure qualified providers • Increase enrolment in ECD from 11% to 25% 72 3.4 Women’s’ empowerment • Girl-centered education in schools and colleges • Train and provide incentives for literacy facilitators and teachers • Establish more and better resourced non- formal basic skills training and literacy centers • Strengthen guidance and counselling within schools • Promotion of women’s livelihoods • Promotion of sexual and reproductive rights (SRHR) • Invest in access by women in mental health services • Ministry of Primary and Secondary Education (MoPSE) • Ministry of Technical and Higher Education (MoTHE) • Increase access to land by women from 42% • A sustained national campaign on the advantages of being literate reaching 100% of the population • All junior secondary and senior secondary schools provide adequate sanitation facilities for menstrual hygiene management • Guidance counsellors trained and equipped in every secondary school with established space for counselling • Out-of-school rate in last year of primary education decrease from 48% to 20% • Increase female literacy rate from 51% to 75% • Increase female enrolment in junior secondary schools from 36% to 60% • Reduction in child marriage by 15years of age from 13% to 5% 3.5 Child protection • Review of capitol policies in schools and communities • Review of child labour policies • MoSWGCA • Training of social workers on nutritional neglect where a child does not receive adequate calories or nutritional intake for normal growth • Safe spaces created, • Mentorship programs developed, and staff/volunteers recruited • Reduction in child labor from 37% to 20% • Reduction in violent discipline of children 1-14 years of age from 31% to 15% 3.6 Classroom education • Revise and introduce nutrition and food security curriculum for primary school children • Revise and introduce comprehensive sexuality education (CSE) in teacher training curricula • Advocate for reduced teaching load (class sizes) • Ministry of Primary and Secondary Education (MoPSE) • Ministry of Technical and Higher Education (MoTHE) • Nutrition and CSE packs developed and disseminated • Nutrition and In-service training of trainers and teachers on CSE • All primary, junior, secondary, and senior secondary schools provide age- appropriate CSE, using culturally relevant approaches 3.7 WASH • Improvement of water sources • Improvement of sanitation by reducing the number of communities practising open defecation • Promotion of handwashing with soap • Improvement of WASH facilities in schools • Improvement of WASH facilities in health facilities • Training and equipping facility user committees to ensure continuous Operation and Maintenance of installed WASH facilities • Rural communities • Leaders & CHWs • WASH committees • Teachers • Village development committees (VDCs) • School health clubs • School management committees (SMCs) • Health facility management committees • Increase of basic water service points from 58% to 75% • Reduction of open defecation from 17.1% to 10% • Increase of hand washing with soap from 41.73% to 75% • Contribute to reduction of diarrhea of children under 5 • Contribute to improvement of infection prevention & control and overall quality of care in health facilities • Contribute to the reduction of stunting and malnutrition 73 79 3.8 Health and Family Planning (FP) services • Avoidance of early teenage pregnancy and child marriage • Provision of FP services for adolescents, WRA and men • Social marketing of FP commodities • WRA • Men of Reproductive Age (MRA) • Teenage pregnancy rate • Modern methods of FP demand met increases from 38% to 75% • Percentage of WRA/MRA who use modern contraceptives increase from 23% to 80% • Percentage of young people 10-24 years receiving FP & counselling messages • Social messaging on HIV targeting adolescents • Average age at first pregnancy increase from to • Median number of months between pregnancies increases from to • Community fertility rate decreases from to • Comprehensive knowledge of HIV amongst adolescent increases from 29% to 80% 3.9 Strategic Information drives decision- making • Improve evidence generation and utilization at national and district level for informed advocacy, planning and intervention actions supporting nutrition, particularly through research led by national institutions to clarify barriers to breastfeeding, early childhood and pregnancy-related nutrition as well as by ensuring that all data and research reports are gender-responsive enabling disaggregation of statistics and action by gender • All stakeholders • Increased knowledge and evidence • Peer reviewed publications and presentations • Evidence-based interventions 3.10 Advocacy & political commitmen t • Proactively engage and increase the role of existing community mechanisms, district councils, parliament, the media and civil society across all development sectors in monitoring progress towards nutrition goals & objectives; This should include increasing the commitment from policymakers, policy advisors, and multi-sectoral program designers at national, district and sub- district levels to accord food and nutrition security a high priority in the political and national development agenda. • Orient new parliamentary members, engaging F&NS champions through the parliamentary network as well as consistently • GoSL • Donors • NGOs • Stakeholders • Increased ownership of nutrition and food security interventions by GoSL and the public • Parliamentarian network on food and nutrition security is established • F&NS champions are identified 79 * Data used is from MICs 6 (unpublished) 74 advocating for the necessary parliamentary F&NS action that advances nutrition and food security 3.11 Improved horizontal and vertical coordination • Build leadership and human capacity at both central and district levels; • Strengthen effective coordination mechanisms which effectively engage and mobilize multiple sectors (e.g. water supply and sanitation, agriculture, food security/livelihoods, education, health, social protection, child protection, etc.) and multiple stakeholders (civil society, development partners, government, private sector), community mechanism such as the Child Welfare Committees and other relevant actors in those coordination mechanisms. • All ministries • Donors • UN agencies • NGO collaboration • Regular inter-ministerial meetings • Donor coordination meeting to avoid duplication of funding/strategies • Information sharing between UN agencies and NGOs • Broaden Nutrition Technical WG to include more Ministries • Ensure the all F&NS (SUN) focal persons within EACH Ministry meet at least quarterly with an emphasis on sustainability and seniority of focal persons • Weekly Food Security Working Group • Quarterly SUN meetings at national level and monthly at district levels • Monthly health NGO meetings with SUN CSO attending • Bimonthly donor meetings • Bimonthly civil society meetings • Bimonthly private sector meetings 3.12 Accountabili ty, incentives, legislation, regulations • Advocate for the development and/or strengthen the coherence of policies and legislation affecting food and nutrition (e.g. Legislation Regulation of the Marketing of Breastmilk Substitutes, National Policy on Salt Iodization, etc) • Consistently emphasize, explicitly-reference and incorporate clear accountabilities for nutrition within other sectoral and inter- sectoral policies and strategic frameworks/plans (particularly in health, agriculture, food security, livelihoods, water supply, sanitation, education, etc), including through inter-ministerial adoption by the Cabinet and subsequent approval by Parliament of the new strategic plan and its accountabilities. • GoSL • Donors • UN agencies • SL Standards Bureau • Reduction of imported baby foods and formula for bottle feeding • Adoption of Codex for packaging and labelling of foods • Adherence to code of conduct for BM substitutes • Develop and enforce SUN Movement Processes Score • Legislation on regulation of CMBSM has been endorsed by parliament • National policy on salt Iodization endorsed • Food safety act endorsed • Right to food and nutrition endorsed • Maternity Protection Legislation • Mandatory Food Fortification • Fortification standards 75 3.13 Domestic Resource mobilisation • Increase the magnitude and transparency of domestic resource mobilization, allocation and disbursement for the effective and efficient delivery of nutrition-related services, while also significantly increasing and incorporating formal transparent accountabilities for the flow and utilization of domestic financial and non-financial resources in support of nutrition, including by ensuring budget lines within each Ministry are dedicated to F&NS and that specific account codes for nutrition and food security are created within key line ministries such as the MOHS • Ensure transparency and credibility or reporting & expenditures. • GoSL • Donors • NGOs • Increased amount of loans granted to agri-businesses at competitive rates • Increased national budget spending for nutrition with budget spending per Child U5 for Nutrition Specific spending • Increased donor funding for nutrition (basic nutrition code in CRS/DAC) • Reduction in food commodity imports 3.14 Supply chain management • Verification matrix trainings to all relevant stakeholders • NMSA established and nutrition commodities included in mandate of NMSA • National plan for integrated supply chain, including nutrition commodities, is developed • Increased distribution of locally produced and processed complementary foods • Nutrition commodities are integrated as part of the supply chain for free health care commodities • Reduction of stock out for nutrition commodities by….. 3.15 Communication and awareness- raising • Develop national SBCC plan • All Ministries • SBCC for nutrition is included in all sectors • All sectors have SBCC for nutrition incorporated in their own sectoral plans • National plan for SBCC and awareness raising is established 3.16 Planning for Equity and prioritization • Identify districts which are food-insecure80 and 50% of other districts experiencing worst acute malnutrition and stunting levels. • Deliver focused sustained support to these districts in order to significantly strengthen their capacity to manage, coordinate, develop and deliver integrated, multi-sectoral, multi-stakeholder, nutrition-specific & nutrition-sensitive interventions involving at least health, agriculture, education, water, sanitation, gender/labor/social welfare sectors. • MOFED • Min of Local Government • SUN Secretariat • District Councils • District Administrators • High food-insecure districts are identified and specific prioritization actions for these districts have been identified • Existence of a multi stakeholder platform in the identified high food insecure districts is operational (regular meetings, agenda, ToR, work plans, all stakeholders present) 80 Based on the regular Ministry of Agriculture, Fisheries and Forestry monitoring supported by the UN’s World Food Program in Sierra Leone. 76 Annex 9. Costing Methods & Optional Formats for “Summary Budget by Objective” Costing Methods & Optional Formats for “Summary Budget by Objective” Submitted for review and approval by TWG on 9 June 2018 I. Budget Background: As an integral part of Draft 1.0 dated 3rd May 2018, this document is submitted by the International Consultant to the Technical Working Group (TWG) overseeing the development of Sierra Leone’s above-mentioned Multi- Sector Strategic Plan. Review and update of the expired NFNSIP 2013-2017 indicated the importance of establishing a budget whose costing is realistic, preferably follows the logical framework or conceptual framework for interventions (nutrition-specific-, nutrition-sensitive & enabling environment interventions) and is attractive for donors to co-invest funding alongside the Government of Sierra Leone’s financing. Thus, and by comparison with the expired NFNSIP 2013-2017, the new strategic plan’s interventions are already prioritized and quite focused on achieving significant progress by 2023. Accordingly, the TWG is kindly requested to discuss and decide which of the 2 format options furthest below should be used to finalize the Summary Budget that will be included in Draft 2.0. II. Costing Methods: A. Pricing Sources, Rationale for Assumptions and New or Changing Variables: The methodology used in costing the budget options below is based on the literature review and stakeholder consultations. Specifically, the new budget draws heavily on the Aggregated Costing Tool (ACT) used by SUN, both in Sierra Leone and elsewhere, which was provided by the MOHS FND in December 2017. The total and relative breakdown of the Sierra Leone NFNSIP 2013-2017 (as generated by the SUN costing mission of March 201381, using the Aggregated Costing Tool or ACT) is now used as a baseline for the costing of this new strategic plan. The SUN costing mission’s report outlined many issues and gaps in the methodologies, assumptions and calculations used to cost the expired NFNSIP. However, there is currently no other reliable method to estimate the total costs of the new strategic plan for the next 5 years other than using the initial 2012-2013 estimates. A key assumption and expectation expressed by stakeholders is that nutrition governance was the key obstacle to advancing nutrition in Sierra Leone, particularly at the district level. Hence, the new nutrition governance component now represents 20% of the new total budget in comparison with the 2.4% in the expired NFNSIP. The 20% is not an arbitrary proportion for nutrition governance. Rather, it is just below the average of 25.4% allocated for nutrition governance by 16 SUN countries reviewed by the SUN mission in 2013. 82 Another factor influencing the relative breakdown of the new plan’s budget between the three main components is the need to invest more in the nutrition-sensitive priorities identified. For instance, it was unusual and inexplicable that the expired NFNSIP did not allocate any funding for the “care environment” in which support to mothers in order to care for themselves and their children is meant to be provided. Hence, in the new plan’s budget, a deliberate increase in the nutrition-sensitive element was made in order to allow 81 Sierra Leone MQSUN SUN Costing. Country visit report. March 2013. Jane Keylock and Meghan Swor. 82 SUN Costing of country plans: Preliminary Summary dated 29 March 2013 - draft dated 2 April 2013. 77 for allocation of funding for the care environment for women and adolescents to strengthen their own and their families’ nutritional status. In terms of financing schedule, Sierra Leone’s expired NFNSIP 2013-2017 has already provided the initial impetus for the heavy expenditures associated with start-up phases of such plans (eg involving recruitment, creation of management and logistics systems, generating behavioral change to increase demand, staff training etc). Moreover, that momentum will be lost if the new plan starts slow. Hence, the schedule for financing the new plan needs to start at a high level in year 1, drop down slightly in years 2,3 and 4 and then taper off in year 5. This logic would indicate that a total budget divided into 25%, 20%, 20%, 20% and 15% yearly proportions would serve that purpose reasonably well. B. Analysis: The sad reality in Sierra Leone was that the gloomy forecast made during the preparation of the expired NFNSIP 2013-2017 has occurred, with international donor support for Sierra Leone’s nutrition efforts shrinking even further. USAID, one of two major donors to Sierra Leone’s nutrition efforts, has ended its SNAP program while consultations with donors revealed that few if any new pledges for continued support to nutrition are currently being made. Significant shifts in donor’s global priorities have certainly occurred and can be partly blamed for this reduced donor interest to invest in Sierra Leone’s nutrition efforts. However, it is additionally possible that the low absorptive capacity, low intervention coverage and weak implementation results may have also contributed to reduced donor interest. Another limiting factor strongly and repeatedly expressed by several stakeholders during the consultations was the weak absorptive capacity in the central and district levels dealing with nutrition in Sierra Leone. The challenge of increasing the attractiveness of investing in nutrition should be seen as an opportunity for policy makers, planners and implementers alike. By strengthening local capacity to absorb current investments to achieve demonstrable results, Sierra Leone will overcome the highlighted weaknesses of the previous NFNSIP and attract more donors to invest in the new plan. In any case, the reduced donor interest now means that domestic financing will now assume a much higher importance for the new plan. It also means that some hard choices must be made in budgeting the new plan; one of which is to drastically reduce its total cost through prioritizing only the most essential elements as well as to reduce the costs of those elements that are preserved. Hence, starting with the initial total cost of the expired NFNSIP (USD 576,904,830) will not be realistic in this funding environment. In response to this context, a heavy and thoughtful intervention prioritization effort has already been applied by stakeholders into the draft new plan. This should serve to drastically reduce the total cost of the new plan’s budget. Tables 1 and 2 below summarize the relative breakdown used in the expired NFNSIP 2013-2017 (Table 1) and the new Multi-Sectoral Action Plan to Reduce Malnutrition in Sierra Leone 2019-2025 (Table 2) based on the above-mentioned analysis. 78 Table 1. Summary Costing of Expired NFNSIP 2013-201783 Component Type Component Cost (in millions of USD) & Percentage of Budget Total Priority Intervention Type Priority Intervention Cost as a Percentage of Component Total Nutrition Specific $ 124.77 21.6% good nutrition practices (including Infant and Young Child Feeding; IYCF) 5.9% acute malnutrition 27.8% vitamin and mineral intake 8.7% nutrient-dense diets 57.6% Nutrition Sensitive $ 438.38 76.0% food security interventions 49.6% health and water and sanitation 50.4% care environment interventions 0.0% Nutrition Governance $ 13.76 2.4% information management 64.8% coordination and partnership 25.8%) systems capacity building programs 9.4% Budget Total $ 576,904,830 It would have been fair to argue for an increase in the new plan’s budget, in light of inflation (15% as of March 2018 according to the Bank of Sierra Leone), population increase (2.2% natural growth according to the UN’s Population Division’s 2017 estimates), additional target groups to be covered (eg adolescents, single female- headed households, urban poor, etc) and the need to achieve coverage gains that are higher than the expired one. However, in light of the shrinking financial envelope from international donors and the low absorptive capacity mentioned above, it would not be realistic nor practical to do so. Accordingly, the new plan’s budget is proposed to be USD 403,833,381 which represents (an admittedly arbitrary) 70% of the above-mentioned total budget in the expired NFNSIP. As more resources become available internationally or domestically, and as absorptive capacity is increased at the implementation level, further program planning and costing should be done in order to add additional interventions or to expand coverage of existing ones to the new plan. Table 2. Summary Costing for Multi-Sectoral Action Plan to Reduce Malnutrition in Sierra Leone 2019- 2025Component Type Component Cost (in millions of USD) & Percentage of Budget Total Year 1 Year 2 Year 3 Year 4 Year 5 Nutrition Specific $ 161,533,352 40 % 40,838,338 25% 32,306,670 20% 32,306,670 20% 32,306,670 20% 24,230,002 15% Nutrition Sensitive $ 161,533,352 40 % 40,838,338 25% 32,306,670 20% 32,306,670 20% 32,306,670 20% 24,230,002 15% 83 Sierra Leone MQSUN SUN Costing. Country visit report. March 2013. Jane Keylock and Meghan Swor. 79 Nutrition Governance $ 80,766,676 20 % 20,191,669 25% 16,153,335 20% 16,153,335 20% 16,153,335 20% 12,115,001 15% Budget Total $ 403,833,381 100,958,345 25% 80,766,676 20% 80,766,676 20% 80,766,676 20% 60,575,007 15% III. Optional Formats for the New Strategic Plan’s “Budget Summary” Chapter: Option A: Only Enabling Environment Priority Interventions costed: Please note that, based on some stakeholder comments on Draft 1.0, the earlier 3rd Strategic Objective (“SO3: To create an enabling environment for central & district multi-sectoral coordination and action”) will now become an Intermediate Result which is necessary (but not sufficient by itself) for the achievement of the other three (new) Strategic Objectives (SOs). In this option, there are two factors representing the compelling rationale for costing only the Enabling Environment Priority interventions. First, and as mentioned in other sections of the plan, the strategic plan is not intended as a fund-raising instrument nor as a set of independent, stand-alone projects operating outside the mainstream of what national and international stakeholders already implement in Sierra Leone. Rather, it is a framework that streamlines, prioritizes, scales-up and intensifies implementation of existing actions while adding few from lessons learned and clarifying the relative roles and interventions for which each stakeholder/sectoral partner is responsible in the effort. Second, a full needs assessment (which typically includes a market survey, wages and salaries analysis, food crop price surveys, etc) was not part of the review and update exercise of the expired strategic plan. Hence, any budget proposed for nutrition-specific or nutrition-sensitive activities would not necessarily reflect an accurate statement of needs. In this option, therefore, the following budget table reflects the costing of just the nutrition governance interventions listed under Enabling Environment as follows: 80 Option A: Only Enabling Environment Objectives costed (in USD) Strategic Objectives Strategic Directions & Priority Activities 84 Intermediat e Result85 Strategic Directions & Priority Activities 86 Estimated Cost of Intermediate Result SO1: To reduce the prevalence of stunted children under 5 years of age (U5C) to 25% SO2: To reduce the prevalence of wasting children under 5 years of age (U5C) to 6.8% SO3: To reduce by 30% the prevalence of deficiencie s iodine, vitamin A, iron & folate deficiencie s in U5C, adolescent s, PLW87 & WRA SD 1: Intensify promotion of optimal care practices affecting nutritionally-vulnerable groups 1. Determine & address key factors (barriers and enablers) affecting MNCH feeding & care practices (including WASH) 2. Holistic baby & child friendly services 3. Feeding practices of U5C, PLW & adolescents & women 15-49 yrs (esp early BF initiation & exclusive BF for 1st 6 months) 4. Prevent nutrition related diseases 5. Access to curative nutrition services SD 2: Strengthen health & community development systems for holistic & responsive delivery of services in conducive and safe environments 1. Prevent nutrition related diseases 2. Manage MCH illnesses 3. Increase ANC, delivery & PPC. 4. Scale-up and rapidly expand IMNCI88 SD3: Improve household food security especially of households with multiple overlapping factors influencing their food security status 1. HH food security improvement; 2. Crop, food & bio-diversification initiatives 3. Food product technologies improvement 4. Food preservation, storage & preparation SD 4: Rapidly increase access to adequate nutrition among target groups by leveraging existing efficient education & social sector service delivery platforms 1. Increase education enrollment & quality 2. School feeding for children & adolescents 3. Scale–up school gardens in each district 4. Use SPPF in cash-based education incentives 5. Scale-up quality WASH structures/systems IR: To create an enabling environmen t for central & district multi- sectoral coordination and action SD5: Prioritize action to strengthen district capacity in nutrition: 1. Prioritize food-insecure89 & 50% of other districts experiencing worst acute malnutrition and stunting levels. 2. Deliver focused sustained support to these districts SD6: Urgently undertake legislative, governance and executive actions to create the necessary enabling environment in support of multi- sectoral nutrition 1. Subsume & mainstream new strategy under national SPPF 2. Advocate coherence F&NS policies & legislation 3. Clear accountabilities for nutrition in all sectors 4. Effective multi-sectoral coordination mechanisms 5. Transparent domestic RM, allocation& disbursement 6. Evidence-generation, utilization at national & district levels 7. Increase DC, parliament, media & CSO governance roles 8. Increase policy-makers’ recommitment for F&NS 9. Quarterly meetings of all F&N ministry focal persons AAAAA90 BBB 84 Abbreviations: MCH=Mother & Child Health; ANC=Antenatal Care; PPC=Post-partum Care; F&NS=Food & Nutrition Security; U5C = Children under 5 years of age; PLW = Pregnant or Lactating Women; SPPF = Social Protection Policy Framework; WASH=Water, Sanitation & Hygiene; MoHS=Ministry of Health & Sanitation, FND=Food & Nutrition Directorate; MP=Members of Parliament; DC=District Council; IMNCI= Integrated Management of Child and Newborn Illnesses. 85 Some stakeholders commenting on Draft 1.0 suggested this governance SO is too vague. Hence, it is stated here as an Intermediate Result enabling the achievement of the SOs, rather than as an SO in itself. 86 Considerable changes in the SD6 Priority Interventions have been made based on stakeholder comments on Draft 1.0. The shorter versions will therefore appear in the budget version to accompany Draft 2.0. 87 PLW = Pregnant or Lactating Women; WRA = Women of reproductive age 15-49 years; U5C = Children under 5 years of age 90 Actual values to be added later after format is approved by TWG 81 Option B: Enabling Environment & all Nutrition-Specific and Nutrition-Sensitive Objectives costed: This second option involves costing all three components at the level of Objectives; namely the three SOs (SO1, SO2 and SO3) as well as the Intermediate Result that focuses on governance. An illustration of how that format would appear is shown below for the TWGs consideration. Option B: Enabling Environment & All Nutrition-Specific and Nutrition-Sensitive Objectives costed (In USD) Strategic Objectives Strategic Directions & Priority Activities 9192 Estimated Cost of Strategic Objectives 93 Intermediate Result94 Strategic Directions & Priority Activities 95 Estimated Cost of Intermediate Result SO1: To reduce the prevalence of stunted children under 5 years of age (U5C) to 25% SO2: To reduce the prevalence of wasting among children under 5 years of age (U5C) to 6.8% SO3: To reduce by 30% the prevalence of deficiencies iodine, vitamin A, iron & folate deficiencies in U5C, adolescents, PLW96 & WRA SD 1: Intensify promotion of optimal care practices affecting nutritionally- vulnerable groups SD 2: Strengthen health and community development systems to ensure a holistic and responsive delivery of services in conducive and safe environments SD3: Improve household food security especially of households with multiple overlapping factors influencing their food security status SD 4: Rapidly increase access to adequate nutrition among target groups by leveraging existing efficient education and social sector service delivery platforms XXXXX IR: To create an enabling environment for central & district multi- sectoral coordination and action SD5: Prioritize action to strengthen district capacity in nutrition: SD6: Urgently undertake legislative, governance and executive actions to create the necessary enabling environment in support of multi-sectoral nutrition AAAAA97 YYYYY BBBBB 91 Abbreviations: MCH=Mother & Child Health; ANC=Antenatal Care; PPC=Post-partum Care; F&NS=Food & Nutrition Security; U5C = Children under 5 years of age; PLW = Pregnant or Lactating Women; SPPF = Social Protection Policy Framework; WASH=Water, Sanitation & Hygiene; MoHS=Ministry of Health & Sanitation, FND=Food & Nutrition Directorate; MP=Members of Parliament; DC=District Council; IMNCI= Integrated Management of Child and Newborn Illnesses. 92 Activities under each of these Strategic Directions will be inserted in Draft 2.0 93 Actual values to be added later after format is approved by TWG 94 Some stakeholders commenting on Draft 1.0 suggested this governance SO is too vague. Hence, it is stated here as an Intermediate Result enabling the achievement of the SOs, rather than as an SO in itself. 95 Considerable changes in the SD6 Priority Interventions have been made based on stakeholder comments on Draft 1.0. The shorter versions will therefore appear in the budget version to accompany Draft 2.0. 96 PLW = Pregnant or Lactating Women; WRA = Women of reproductive age 15-49 years; U5C = Children under 5 years of age 97 Actual values to be added later after format is approved by TWG 82 Annex 10: Process Milestones in the Review and Update of NFNSIP 2013-2017 • November 2017: Desk review of literature provided by stakeholders98 • 7 December 2017: Consultative Stakeholder Workshop held in Freetown • December 2017-January 2018: Semi-structured interviews with individual stakeholders • January 2018: Focus group discussions with district-based stakeholders • February 2018: Data and information analysis of progress achieved and lessons learned • 26 February 2018: Data Validation Workshop held in Freetown • March-April 2018: National elections and run-off elections held in Sierra Leone • March-April 2018: Developing Data Workshop Report and Draft 1 of new strategic plan99 • 24 July 2018: Full Validation Workshop held in Freetown • By 31 July 2018: Incorporating Validation Workshop comments to develop Draft 2 • By 30 October 2018: Incorporation of final comments and submission of Final Draft 3. 98 Stakeholders refers to all partners consulted during the review process, including Government (at both central and district level), Sierra Leonean civil society organizations (CSOs), international non-governmental organizations (NGOs), United Nations agencies (UN), national research institutions and donors represented in Sierra Leone. 99 Submission of Draft 1.o was delayed from its original 20th March 2018 deadline due to extended data validation processes within key stakeholder institutions as well as because of the run-off phase of the national elections.