National Food and Nutrition Security Policy 2012-2016

MINISTRY OF HEALTH AND SANITATION Sierra Leone National Food and Nutrition Security Policy 2012 - 2016 1 Contents LIST OF ACRONYMS 3 FOREWORD 6 ACKNOWLEDGEMENT 5 CHAPTER 1: NATURE, EXTENT AND CAUSES OF FOOD SECURITY AND NUTRITION PROBLEMS IN SIERRA LEONE 6 1.1 Background 7 1.2 Situation Analysis 8 1.2.1 Basic statistics 8 1.3 Food and Nutrition Security Situation 8 1.3.1 Food security 8 1.4 Nutrition Situation 9 1.4.1 Undernutrition 9 1.4.2 Micronutrient malnutrition 9 1.4.3 Diet related non-communicable diseases 10 1.4.4 Health Situation 10 1.5 Underlying Causes of Food and Nutrition Situation 10 1.5.1 Factors contributing to inadequate food supply 10 1.5.2 Factors contributing to ineffective food utilization 11 1.5.3 Factors contributing to inadequate feeding practices 11 1.5.4 Other factors 12 CHAPTER 2: GOALS AND OBJECTIVES OF THE NATIONAL FOOD AND NUTRITION SECURITY POLICY 13 2.1 Vision 13 2.1.1 Goal 13 2.1.2 General Objective 13 2.1.3 Specific Objectives (SO) 13 2.2 Policy Directives 13 2.3 Guiding Principles 15 CHAPTER 3: STRATEGIES FOR ACHIEVING THE FOOD AND NUTRITION SECURITY POLICY OBJECTIVES 16 2 3.1 Specific Objective 1: Advocacy on Nutrition Issues 16 3.2 Specific Objective 2: Promoting and Facilitating Adequate National and Household Food Security 16 3.2.1 Increasing production and supply of food 16 3.2.2 Improving access to food 17 3.3 Specific Objective 3: Adoption of Appropriate Feeding Practices for Households 17 3.4 Specific Objective 4: Strengthening of Preventive Measures against Nutrition Deficiency and other Related Diseases 18 3.5 Specific Objective 5: Provision of Curative Services to Malnourished Individuals 19 3.6 Specific Objective 6: Nutritional Surveillance System 20 3.7 Specific Objective 7: Research into Food and Nutrition Issues 20 3.8 Specific Objective 8: Coordination of Nutrition Activities 21 CHAPTER 4: INSTITUTIONAL ARRANGEMENTS 22 4.0 Implementation Mechanism for the Sierra Leone National Food and Nutrition Policy 22 4.1 Functions of Nutrition Technical Committee 22 4.2 Functions of Nutrition Technical Committee at district level 22 4.3 Functions of MOHS 23 4.4 Functions of other Line Ministries 23 4.5 UN Agencies 24 4.6 International NGOs 24 4.7 Local NGOs and CBOs 24 4.8 Private Sector 24 4.9 Funding 24 5.0 RELATED DOCUMENTS 25 3 LIST OF ACRONYMS BFHI Baby Friendly Hospital Initiative CBIMCI Community Based Integrated Management of Childhood Illnesses CBO Community Based Organisations CMAM Community Management of Acute Malnutrition CEDAW Convention on Elimination of Discrimination Against Women DHMT District Health Management Team GDP Gross Domestic Product GMP Growth Monitoring and Promotion GoSL Government of Sierra Leone IMR Infant Mortality Rate LBW Low Birth Weight MAFFS Ministry of Agriculture, Forestry and Food Security MCH Maternal and Child Health MDG Millennium Development Goals MFMR Ministry of Fisheries and Marine Resources MI Micronutrient Initiative MICS Multiple Indicator Cluster Survey MMR Maternal Mortality rate MOFED Ministry of Finance and Economic Development MEST Ministry of Education, Science and Technology MOHS Ministry of Health and Sanitation MOTI Ministry of Trade and Industry 4 MTASP Medium Term Agricultural Strategic Plan NCD Non Communicable Disease NGO Non-Governmental Organisation NL Nutrition Lens PHC Primary Health Care PHU Peripheral Health Unit PLWHA People Living With HIV/AIDS PRSP Poverty Reduction Strategy Paper Pop/FLE Population Family Life Education RCH Reproductive and Child Health SL-DHS Sierra Leone Demographic and Health Survey SO Specific Objective TB Tuberculosis UNICEF United Nations Children’s Fund VAS Vitamin A Supplementation WFP World Food Programme WHO World Health Organization 5 FOREWORD The Ministry of Health and Sanitation with the support and collaboration of its partners has revised the National Food and Nutrition Policy after extensive consultations. This document marks an important milestone in the efforts of the Government through the Ministry of Health and Sanitation to effectively address the food and nutrition needs of all sectors of the population. This achievement is a manifestation of the commitment of Government and its partners in the health sector to pursue policies and programmes that will ensure effective service delivery in order to improve the quality of life of the population. An important focus of the document is advocacy for policy advisors, development partners, and programme designers at national and district levels. It highlights the relationship between nutrition and the overall development agenda, and points out the need for incorporating nutritional considerations in various development policies to ensure proper targeting of vulnerable sectors of the population. The policy document serves as an important tool in the promotion and facilitation of household food security and appropriate infant and young child feeding practices, and it promotes strategies that strengthen preventive measures against nutrition-related diseases. Obtaining the full impact of the measures described in this document will depend on the collaborative and sustained efforts of government line ministries and various UN agencies, NGOs, and Civil Society Organisations. These measures represent a multifaceted approach in addressing the issues of the availability of and access to food. They include measures in communities and households to ensure proper utilization of food, appropriate care and support to vulnerable members of families and communities, and effective coordination, monitoring, and supervision of the actions of the various stakeholders to assure sustainability. In this way, issues relating to nutrition as a major cause for morbidity and mortality in children and women will be minimized. We trust that you will find this revised Food and Nutrition Security Policy document useful. We invite you to join forces with the government to roll out the revised policy, and to implement the proposed intervention strategies. Zainab Hawa Bangura (Mrs) Minister of Health and Sanitation 6 ACKNOWLEDGEMENT The Government of Sierra Leone under the technical supervision of the Food and Nutrition Programme of the Ministry of Health and Sanitation has produced the revised National Food and Nutrition Policy. The entire work was a collaborative effort of many stakeholders including individuals, government ministries, UN agencies, international and non-governmental organizations (NGOs). The Ministry of Health and Sanitation is grateful to all those who in one way or the other contributed to reviewing the country’s national policy on food and nutrition. Special thanks go to the drafting committee, which comprised a sub-committee of the National Nutrition Committee that included representatives of UNICEF, WFP, WHO, the Sierra Leone Standards Bureau, HKI and various line ministries. They contributed immensely to the production of the first draft of the policy document. The draft was extensively reviewed and validated by multiple key stake holders including the Ministries of Agriculture, Forestry and Food Security, Education, Youth and Sports, Social Welfare, Gender and Children’s Affairs and Finance and Economic Planning. . Our profound appreciation goes to WHO, UNICEF, WFP and HKI, for their technical and financial support towards the production of this document. The Ministry of Health and Sanitation on behalf of the government graciously thanks the international consultant, the various UN agencies’ representatives, and those individuals whose contributions ultimately improved the quality of the document for their assistance as well as for their invaluable support in promoting the wellbeing of children and women in Sierra Leone. Alhaji Dr. Kisito S. Daoh Chief Medical Officer Ministry of Health and Sanitation 7 CHAPTER 1: NATURE, EXTENT AND CAUSES OF FOOD SECURITY AND NUTRITION PROBLEMS IN SIERRA LEONE 1.1 Background Since gaining independence in April 1961 Sierra Leone has withstood many challenges, including instability and poverty. At the time of independence in 1961, Sierra Leone’s economic prospects were promising. The economy grew significantly during the 1960s, by about 4.5 percent per annum, due mainly to mining, agricultural production and exports. The economy, however, slowed down during the 1970s and 1980s as the effect of the decline in corporate mining spread through the monetized economy. Financial and associated economic decline was also caused by adverse international market conditions for domestic exports and inappropriate domestic policies. 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. Despite the tremendous efforts by Government and development partners to raise living standards for the Sierra Leonean population, the country’s poverty profile is still unsatisfactory and has contributed to low health and nutritional status of the population. Several international conferences have been held to find solutions to global food insecurity, famine and under-nutrition. To mention but a few, the United Nations Conference on Food and Agriculture held in 1943 had an overall objective of achieving “an adequate diet for all”; The World Summit for Children (1990) focused on the improvement of the nutrition of children; The International Conference on Nutrition (1992) and World Food Summits (1996 & 2002) addressed equity of food distribution and macro- and micro-nutrient malnutrition among children and women. Sierra Leone recognizes international conventions and treaties on the right to adequate food as a fundamental human right (as listed in Article 25 (1) of the Universal Declaration of Human Rights and Articles 11(1) and 11(2) of the International Covenant on Economic, Social and Cultural Rights). In the last decade, the Government has formulated a number of strategy documents aimed at improving the living standards of the population. The most recent ones are the first generation Poverty Reduction Strategy Paper (SL-PRSP, 2007), and the newly launched Poverty Reduction Strategy under the President’s Agenda for Change. The strategy highlights food security and nutrition as growing challenges for Sierra Leone. The objectives are set with reference to the Millennium Development Goals (MDGs), which aim at reducing poverty and its various symptoms by 2015 and which call upon the international community to strive side by side with national governments to achieve these goals within a partnership and cooperative framework. Sierra Leone started the implementation of the full PRSP in 2005, only ten years before the target date of 2015. The recently concluded MDG Progress Report for Sierra Leone indicates that the country would meet only two out of eight of the MDGs if current trends continue (GoSL, 2010). In the Agenda for Change, food and nutrition security elements such as agriculture, fisheries and malnutrition have been identified as key in addressing the challenges involved in reducing poverty and therefore form components of the backbone in constructing the country’s poverty reduction strategy. The Food and Nutrition Security Policy is intended to serve as a framework to address the challenging food security and nutrition situation outlined in the PRSP. 8 1.2 Situation Analysis 1.2.1 Basic statistics The population of Sierra Leone is estimated at about 5,866,000 (2011) and about 66 % of the population lives in rural areas (SLPRSP, 2005-7). It is estimated that about 75 % of the population live in poverty and that more than two-thirds of the poor could be described as living in conditions of extreme poverty (SLPRSP, 2005-7). At the national level, about 26 % (1.5 million) of Sierra Leoneans cannot afford adequate daily food intake to sustain a healthy life (SLPRSP, 2005-7). The major consequences of malnutrition are morbidity and mortality and the groups most affected are women and children. The World Health Organisation (WHO) has estimated that malnutrition is associated with over a third of all child deaths that occur in developing countries. Infant mortality rate (IMR) in Sierra Leone has reduced from 140 per 1000 live births in 2003 to 89 per 1000 live births (SLDHS 2008). Similarly, under-five mortality rate has reduced from 190 per 1000 live births 10-14 years before the 2008 SLDHS survey to 140 per 1000 live births for the 5-year period before the survey (SLDHS 2008). Maternal mortality ratio (MMR) is estimated to be 857/100,000 live births (SLDHS 2008) and even though this high rate is primarily due to unsafe obstetric care, it can also be attributed to poor nutrition. Life expectancy at birth is 34.3 years (35.6 years for females and 33.1years for males - SLPRSP, 2005-2007). Even though these statistics show a downward trend especially in infant and under five mortality rates, the current situation is still unacceptably high and indicates the need to further strengthen strategies to overcome the main immediate and underlying causes of the situation. 1.3 Food and Nutrition Security Situation 1.3.1 Food security The Comprehensive Food Security and Vulnerability Analysis survey (CFSVA 2011) found out that nationally almost half (45%) of households or 2.5 million people are classified as food insecure during the lean season, reflecting seasonal food access issues. Of those about 374,000 people (6.5%) are severely food insecure. Hunger peaks in August with people’s access to food starting to deteriorate in June and July. This classification is based on having a poor or borderline diet as noted by the Food Consumption Score (FCS). The livestock sub-sector grows at a slower rate than crop production. Livestock holdings are small in size, dispersed and, except for chickens and small ruminants, there are cultural constraints with regards to their improvement. The relatively high cost of meat products has increased the demand for fish. Over 100,000mt of fish is produced annually, making the sector a major contributor to the enhancement of livelihoods of the poor in most fishing communities. However, about 75% of the catch by foreign trawlers is exported, and the artisanal fisher folk, who supply the bulk of the fish for the local population, do not have the capacity to satisfy the market. 9 1.4 Nutrition Situation 1.4.1 Undernutrition The prevalence of low birth weight (LBW) is estimated at 24% (MICS3), a level that is well above the regional average of 15 percent 1 .The Sierra Leone Demographic and Health Survey (SLDHS 2008) revealed that 36% of Sierra Leonean children are stunted, with 21% being severely stunted and stunting peaks at 48 % among children aged 24-35 months. This is an indication of the prevalence of chronic household food insecurity. The survey also found the proportion of children suffering from wasting to be 10%, with 4% being severely wasted. Almost one-fifth of Sierra Leonean children are underweight, with 7% classified as severely underweight. However, findings of the recently conducted Standardized Measurement and Assessment of Relief and Transition (SMART, 2010) survey showed that 327,000 (34.1%) are stunted with 9.5% severely stunted, whilst 180,000 (18.7%) are underweight with 4.3% severely underweight. It was also noted that 66,000 (6.9%) children are wasted and 0.9% are severely wasted. Even though the trend shows that Sierra Leone is making progress in reducing malnutrition, these absolute numbers of malnourished children still remain high 1.4.2 Micronutrient malnutrition Anaemia is a major problem especially among young children and pregnant women. Overall, 76% of children aged 6-59 months have some level of anaemia: 28 % of children are mildly anaemic, 44% moderately anaemic, and 4 % have severe anaemia 2 . The prevalence of any anaemia among women age 15-49 in Sierra Leone is 46 %: 34% mildly anaemic, 11% anaemic, and less than 1% severely anaemic (SLDHS 2008). Of children aged 8-14 years, approximately 34% were found to have low urinary levels of iodine (less than100 µg/l – Nutrition National Survey 2003). The percentage of households that consume adequately iodized salt in Sierra Leone has doubled in the past five years and 58.2% of households now consume salt that is adequately iodized3 (SLDHS 2008). The lack of in-country facilities to iodize locally produced salt continues to hamper efforts to achieve universal salt iodization. Vitamin A deficiency affects about 47% of the under five population (UNICEF/MI 2004), largely due to diets lacking in vitamin A-rich foods 4 . In 2010, 91% of children aged 6-59 months received 1 One of the major challenges in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased because the majority of newborns are not delivered in facilities; those who are born in facilities represent a select sample of all births that is not representative of the overall population. 2 The classification is based on criteria developed by WHO (De Maeyer et al., 1989) as follows: Mild: haemoglobin concentration 10.0-10.9 gldl; Moderate: haemoglobin concentration 7.0-9.9 g/dl; Severe: haemoglobin concentration less than 7.0 g/dl 3 GoSL policy states that all salts imported into the country should be iodized. However, local production of non-iodized salt in costal communities continues and this salt is sold in the market. 4 Based on UNICEF/WHO guidelines, the Sierra Leone Ministry of Health and Sanitation (MoHS) recommends that children aged 6-11 months be given one high dose Vitamin A capsule (100,000 IU) and children aged 12-59 months be given a vitamin A capsule (200,000 IU) every 6 months 10 a high dose vitamin A supplement during the six months prior to the SMART 2010 survey. Vitamin A Supplementation (VAS) coverage among postpartum women is 55% (SLDHS 2008). 1.4.3 Diet related non-communicable diseases Hospital reports indicate that Sierra Leone is experiencing a marked upsurge of chronic Non Communicable Diseases (NCDs) with dietary implications such as hypertension and its complications, diabetes and gout. There is an increase in the admission of such cases in hospitals. The SLDHS 2008 revealed that 8% of young children are overweight. The highest proportion of overweight children is in the age group below 9 months; 12% of children in that age group are overweight. 1.4.4 Health Situation Malnourished children have impaired immune systems that predispose them to sickness and death. Nutrition is intimately interrelated with communicable diseases such as HIV and tuberculosis and it plays an important role in the etiology, complications and therapy of these diseases. Women who are malnourished are more likely to face reproductive problems that can lead to maternal and infant deaths. Improved nutrition reduces the severity of some diseases and minimizes the incidence of others. 1.5 Underlying Causes of Food and Nutrition Situation Three clusters of underlying factors lead to the achievement of adequate dietary intake and low incidence of disease. These are: (1) adequate supply of safe and nutritious food in a household to meet the physiological needs of all household members all year round. (2) Adequate sanitation in and around homes, hygienic handling of food, coupled with access to adequate health services. Infections speed nutrient loss and suppress appetite of sick children who subsequently do not eat as much as they should and the cycle continues. (3) Adequate care for women and children encompassing all measures and behaviours that translate the availability of food and health resources into good child growth and development 1.5.1 Factors contributing to inadequate food supply Several factors contribute to inadequate supply of food at the household level. Low agricultural productivity due to dependence on rain-fed agriculture, droughts, floods and pests have exerted additional pressures on the chronically poor. In most locations, farmers rely heavily on human labour for land preparation, weeding, and harvesting. Low asset endowments of small scale farmers combined with endemic livestock diseases limits animal production, productivity, and traction. Insufficient access to food at the household level by large parts of the population could be attributed to two factors: (1) lack of financial resources to purchase food on a continuous basis. The incidence of poverty in the country is highest in the agricultural sector, with about 79% of those engaged in the sector being poor. The intensity of poverty in the agricultural sector is more than twice as high as in the construction sector (2) lack of physical access to the food due to 11 inadequate infrastructure such as markets and roads to transport the food, lack of storage facilities and high post-harvest losses resulting in high food prices. 1.5.2 Factors contributing to ineffective food utilization Even when nutritious food is available in adequate quantities, proper food utilization requires that an individual be able to consume diversified, properly prepared safe foods and effectively absorb the energy and nutrients in the foods consumed. Diseases such as diarrhea, respiratory conditions, measles, malaria, TB and HIV/AIDS 5 interfere with proper food utilization. Other factors including access to reliable health services and living in sanitary environments with access to potable water are necessary for proper food utilization. The general population utilization rate of health care facilities in Sierra Leone is estimated at 0.5 contacts per capita per annum, implying that only one-half of the population attends a health care facility once a year. In addition, only 66% of households have both an improved source of drinking water and improved sanitation facilities (CFSVA 2011). 1.5.3 Factors contributing to inadequate feeding practices The reasons behind the rising rates of malnutrition and micronutrient deficiencies remain ingrained in traditional and cultural beliefs, as well as knowledge, attitudes and practices regarding infant and young child feeding. Even though breastfeeding is very common in Sierra Leone and the duration of breastfeeding is long, only 11% of children less than 6 months of age are exclusively breastfed 6 and only 47% of newborns are given breast milk within one hour of birth. Overall, feeding practices meet the minimum standards for only 23 percent of children age 6-23 months (SLDHS2008). The most common problem with feeding practices in Sierra Leone is an inadequate number of feedings and therefore many children lack nutrients essential for survival, growth and development. Sub-optimal feeding practices in early childhood contribute immensely to the progressive increase of malnutrition levels in children in the first two years of life. However by age 6-9 months, more than 90% of children are still being breastfed, and most breastfeeding children are receiving complementary foods in addition to breast milk. The rising incidence of diet related diseases reflects the changing dietary practices of the population. The food a person consumes translates into the type of diet related disease to which he or she is susceptible and also affects how well the body heals itself. 5 For example, HIV and tuberculosis affect food utilization in several ways: they reduce the infected person’s appetite and ability to take food, as well as the body’s ability to absorb ingested nutrients. At the same time metabolic changes actually increase nutritional needs. (WHO estimates an increase in energy needs by 10 percent for HIV-positive asymptomatic adults, between 20 and 30 percent for HIV-positive symptomatic adults, and between 50 and 100 percent for HIV positive children with weight loss). 6 Following international guidelines, the Ministry of Health and Sanitation in Sierra Leone recommends that infants be exclusively breast-fed from birth to about 6 months of age. 12 1.5.4 Other factors Human resource The public health service delivery system has three tiers and is based on the Primary Health Care (PHC) strategy. Presently services are provided by five (5) Government tertiary referral hospitals, 45 government and private secondary hospitals, and 1,092 Peripheral Health Units (PHUs). There are 300 Maternal and Child Health (MCH) aides in paid government employment as well as several trained MCH aides that are not receiving government salaries but are working in government PHUs. The public sector has 1477 beds, 211 doctors and dentists, 8 Pharmacists, 261 Registered nurses, 250 Enrolled nurses, 144 community nurses, 122 public health officials and 8 laboratory technologists. The number of physicians per 100,000 persons is estimated at nine (PRSP). There are 13 nutritionists within the health sector. Two of them are located at the National level, with two in hospitals and nine with the District Health Management Teams (DHMTs). There are wide variations in the number of health care workers available per district with an overconcentration of health personnel per capita in the Western area. Education The level of education especially of women contributes to the high incidence of malnutrition. 66% of women have never been to school, compared with 50% of men. Likewise, men (18%) are three times more likely than women (6%) to have attended senior secondary school (SLDHS 2008). The SLDHS 2008 also indicates that children of mothers with some secondary or higher education are much less likely to be stunted than children whose mothers achieved only the primary level or never attended school. 13 CHAPTER 2: GOALS AND OBJECTIVES OF THE NATIONAL FOOD AND NUTRITION SECURITY POLICY The problem of malnutrition is of a multifaceted nature and so the Government of Sierra Leone calls for a multisectoral effort in implementing the National Food and Nutrition Policy. 2.1 Vision A healthy and well nourished population with communities and families well informed and empowered to take appropriate action on their food and nutrition situation. 2.1.1 Goal The overall goal of the National Food and Nutrition Policy is to contribute to the improved health, social and economic well-being of all the people in Sierra Leone, especially women, children and other nutritionally vulnerable groups. 2.1.2 General Objective To improve the current nutritional status of the population, especially infants and young children, pregnant and lactating women and other vulnerable groups in Sierra Leone 2.1.3 Specific Objectives (SO) I. To undertake advocacy for policy makers, policy advisors and programme designers at national and district levels on nutrition and its relationship to development. II. To actively promote and facilitate adequate household food security (quantity, quality and safety) to satisfy the daily dietary needs of the population. III. To promote adoption of appropriate feeding practices by households. IV. To strengthen preventive measures against nutrition related diseases V. To provide curative services to individuals who are either malnourished or present a condition requiring diet therapy. VI. To institute a nutritional surveillance system for monitoring the food and nutrition situation in the country. VII. To promote operational research and periodic surveys into food and nutrition issues VIII. To coordinate activities of relevant agencies involved in food and nutrition issues 2.2 Policy Directives The following policy directives will underpin the specified objectives: 14 SO1. To undertake advocacy for policy makers, policy advisors and programme designers at national and district levels on nutrition and its relationship to development. Policy: All relevant organizations should integrate nutrition considerations in programmes and activities SO2. To actively promote and facilitate adequate household food security (quantity, quality and safety) to satisfy the daily dietary needs of the population. Policy: Small scale farmers should be provided effective support to improve their food production and supplies and enhance the quality and safety of foods produced. SO3. To promote adoption of appropriate feeding practices of households Policy: a. Protect, promote and support early and exclusive breastfeeding for infants from birth until six months, followed by introduction of nutritious and appropriate complementary foods with continued breastfeeding for two years and beyond. b. Promote appropriate feeding practices for the family especially pregnant and lactating women at facility and community levels. SO4. To strengthen preventive measures against nutrition related diseases Policy: Antenatal, Postnatal and Family Package services should be promoted and introduced at the community level especially through outreach clinics SO5. To provide curative services to individuals who are either malnourished or present a condition requiring diet therapy. Policy: a. Patients in hospitals as well as all malnourished people living with HIV/AIDS (PLHIV) and tuberculosis (TB) clients should be provided with optimum dietary services to complement their clinical management. b. Community-based Management of Acute Malnutrition (CMAM) approach should be integrated into child survival and development initiatives SO6. To institute a nutritional surveillance system for monitoring the food and nutrition situation in the country Policy: A regular and coordinated food and nutrition surveillance system that assists in long term health and development planning, programme management, timely warning and design of intervention programmes should be instituted SO7. To promote operational research and periodic surveys into food and nutrition issues 15 Policy: Effective operational research and periodic surveys aimed at improving food security and nutrition should be integrated into programmes of relevant research institutions SO8. To coordinate activities of relevant agencies involved in food and nutrition issues Policy: The Nutrition Division of the Ministry of Health and Sanitation should ensure that activities to address nutrition issues are reflected in plans of other programmes and implemented in a multisectoral, coordinated manner 2.3 Guiding Principles The policy is based on the following guiding principles: that adequate food and nutrition is a fundamental human right that the government with support from development partners takes necessary measures to ensure national food security through emergency preparedness for times of crises such as floods and droughts that the policy is owned by the government and supported by development partners that the policy is linked with other policies and national documents such as PRSP, MDG, UN Joint Vision and other WB and EU visions that the policy on food and nutrition is part and parcel of the overall national health and development policy that gender considerations and the needs of all vulnerable groups are integral to all components of the policy that the Sierra Leone Government is accountable and obligated to improve the food security situation in the country as set out in national laws and international conventions, treaties and resolutions on the right to food that there is good collaboration between the stakeholders that in the planning, budgeting and implementation of the policy, a rights-based approach will be adopted to promote and protect the right to adequate food and nutrition, ensuring the participation of the rights’ holders. that the Government of Sierra Leone will adopt, promulgate and implement the food and nutrition policy and plan of action for the improvement of the quality of life of Sierra Leoneans. 16 CHAPTER 3: STRATEGIES FOR ACHIEVING THE FOOD AND NUTRITION SECURITY POLICY OBJECTIVES To achieve the objectives of the food and nutrition policy, the following strategies have been defined for each of the specific objectives outlined. 3.1 Specific Objective 1: Advocacy on Nutrition Issues Policy: All relevant organizations should integrate nutrition considerations in programmes and activities Key strategies Communicate nutrition policy at national and district levels Develop mechanism to involve other sectors in formulation of food and nutrition activities at national and district levels Develop a continuous programme for dissemination of information to key decision makers at national and district levels Explore avenues within programmes of relevant sectors to integrate nutrition using the “Nutrition Lens” (NL) approach 7 3.2 Specific Objective 2: Promoting and Facilitating Adequate National and Household Food Security 8 Policy: Small-scale farmers should be provided with effective support to improve domestic food production. Key strategies 3.2.1 Increasing production and supply of food Ensure availability of adequate and appropriate technologies together with improved agricultural inputs at the appropriate time especially for the poorer groups 7 Nutrition Lens is a tool for analysis, planning and programme delivery. The aim of NL is to facilitate, coordinate and leverage opportunity. Applying Nutrition Lens across sectors is evidence of national political commitment to end hunger and malnutrition. It provides a policy and planning tool to: ensure MDGs are seriously considered in the investment planning process; integrate nutrition “best practices”; encourage awareness of the impacts of poor policy decisions; ensure development investments “do no harm”; encourage coordinated management, information exchange and monitoring. 8 The main strategic approaches to improve the situation of the rural poor include measures to increase agricultural production and productivity and prevent post harvest losses. These measures are already addressed in the “Medium Term Agricultural Strategic Plan” (MTASP) and therefore not repeated here. 17 Expand Operation Feed the Nation programme 9 to cover all vulnerable districts Integrate nutrition activities into the Farmer Field School programme, which is designed for decentralized community-based market organizations 10 or Agricultural Business Centres. Establish partnership with consumer protection organisations Strengthen and implement community based agriculture extension services 3.2.2 Improving access to food Collaborate with private sector to improve food storage, processing with value addition, marketing and distribution systems for local markets 11 Document, promote and improve indigenous food processing techniques and their use at the household level Train communities on different food processing, preservation and packaging techniques Promote food diversification in communities and at all levels Identify and implement income generating ventures which are sustainable for rural women Encourage and provide support for dry-season gardening for vulnerable households to ensure access to food supplies all year round. Strengthen and implement national food standards and laws including code and guidelines on food safety and hygiene for locally produced and imported foods 3.3 Specific Objective 3: Adoption of Appropriate Feeding Practices for Households Policy: 1. Protect, promote and support early and exclusive breastfeeding of infants including HIV infected infants from birth until six months, followed by introduction of nutritious and appropriate complementary foods with continued breastfeeding for up to two years and beyond. 2. Promote appropriate feeding practices for the family especially pregnant and lactating women and other vulnerable groups at facility and community levels. 9 In 2002, with FAO support, the Government of Sierra Leone launched the Operation Feed the Nation under the Ministry of Agriculture, Forestry and Food Security and within the framework of the National Recovery Strategy and now the National Poverty Reduction Strategy. 10 Decentralized community-based market organizations are being created through Farmer Field Schools, Agricultural Business Units and District Networks. In addition, food security activities such as Food Security through commercialization, school gardens, value added activities, income generation, post harvest losses, awareness raising on HIV/AIDS, Tuberculosis(TB), malaria control programmes, adult literacy programmes, mechanisation, social safety nets, infrastructures, and community banking/village saving schemes have been incorporated into Operation Feed the Nation. 11 Fourteen District Networks for marketing, commercialization and credit have been established by over 40 000 farmers involved in Operation Feed the Nation. Literacy and health issues are being incorporated into the on-going up scaling stage by the Government of Sierra Leone. 18 Key strategies Develop, adopt and implement Code on Marketing of Breast Milk Substitutes Promote and strengthen the implementation of Baby Friendly Hospital Initiative (BFHI) and Baby Friendly Community Initiative (BFCI) Support the promotion of exclusive breast feeding for HIV - exposed infants aged 0 – 6 months and continuous breast feeding until 12 months while complementary food is added at 6 months and mother continues to take triple ARV or lifelong ART. Promote complete weaning from breast milk at 12 months for HIV- exposed infants while mothers who do not yet require ART for their own health should stop triple ARV one week after the cessation of all breast feeding. Promote appropriate complementary feeding for children from six months to two years, and optimum feeding practices for children 2-5 years Develop nutrition messages aimed at decision makers in households (fathers, grandmothers) Integrate feeding counseling for pregnant and lactating women into antenatal, post natal and outreach services. Support adequate dietary and nutritional intake as part of successful treatment programme for persons with TB and/or HIV through provision of nutritional counseling and linking individuals to services 3.4 Specific Objective 4: Strengthening of Preventive Measures against Nutrition Deficiency and other Related Diseases 12 Policy: Antenatal, Postnatal and the Family Package services should be introduced and promoted at the community level especially through outreach clinics 13 . Key strategies Ensure mass distribution/routine of vitamin A capsule to children 6-59 months of age and postpartum women Ensure routine de-worming of children 12-59 months and pregnant women in the second trimester Intensify the delivery of the integrated ante-natal, post natal and family packages using available structures at community level. 12 The provision of safe drinking water and sanitation has been a major intervention under the National Recovery Strategy and is part of many rural development programmes and projects implemented in the country. The PRSPP envisages the promotion of human development with a comprehensive set of measures which will bring about improved food utilization: Education, health, water supply and sanitation. 13 The Family Package includes interventions such as insecticide treated bednets, exclusive breastfeeding, immunizations, complementary feeding, nutritional supplements, use of iodised salt. Antenatal package includes interventions such as deworming, insecticide-treated bednets, iron-folate supplementation and use of iodised salt. Post natal package includes breastfeeding, GMP, Vitamin A and iron folate supplementation, health and nutrition education 19 Promote the production and consumption of locally available micronutrient-rich foods. Fortify widely consumed foods such as wheat flour and locally produced complementary foods with iron, B vitamins, vitamin A and other appropriate minerals Collaborate with relevant programme managers to strengthen and implement packages (ante-natal, post natal and family) Ensure that all salt for human and animal consumption is fortified with adequate levels of iodine Strengthen other public health measures to protect the vulnerable groups, such as increased access to potable water and sanitation facilities Ensure that all health and other relevant personnel are trained on the appropriate application of guidelines for the nutritional management of people living with HIV/AIDS (PLHIV) and tuberculosis (TB) patients. Use Essential Nutrition Actions (ENA) to consolidate the technical content of the various nutrition messages to serve as the basis for education and information sharing Promote and implement community based Growth Monitoring and Promotion (GMP) Use all available channels of communication 14 for public education on food and nutrition 3.5 Specific Objective 5: Provision of Curative Services to Malnourished Individuals Policy: 1. Patients in hospitals as well as all malnourished people living with HIV/AIDS (PLHIV) and tuberculosis (TB) clients should be provided with optimum dietary services to complement their clinical management. 2. Community-based Management of Acute Malnutrition (CMAM) approach should be integrated into child survival and development initiatives Key strategies Ensure effective therapeutic and supplementary feeding for sick and malnourished children based on local foods Establish functional nutrition units comprising nutrition and catering staff and headed by a nutritionist/dietician in all hospitals Revise national protocol on CMAM Conduct training and capacity building activities for health workers and health volunteers to equip them to implement the CMAM approach and protocols as well as supplementary feeding. Use all available channels of communication for sensitizing communities on availability of services for malnourished children Scale up the Community-Based Integrated Management of Child Illness (CBIMCI) initiative in all districts of the country 14 Different media (short movies, TV, radio, posters, leaflets) should be used for public campaigns depending on media access by the intended clients (urban, rural, remote rural, illiterate, women, mothers, fathers etc) 20 Create awareness and mobilize communities to utilize available nutrition services within the PHUs Conduct training and capacity building activities for health workers and health volunteers on nutritional assessment, education and counseling with specific focus on PLWHA and TB clients including infant feeding. Scale up nutritional rehabilitation of malnourished PLWHA and TB clients (incl. support for affected households where necessary), as well as livelihood activities to enable continuum of care 3.6 Specific Objective 6: Nutritional Surveillance System Policy: A regular and coordinated food and nutrition system that assists in long term health and development planning, programme management, timely warning and design of intervention programmes should be instituted Key strategies Develop early warning system incorporating food security and nutrition status indicators Adapt child growth chart using the new 2006 WHO standards Promote and implement Community based Growth Monitoring and Promotion (CBGMP) 3.7 Specific Objective 7: Research into Food and Nutrition Issues Policy: Effective operational research and periodic surveys aimed at improving food security and nutrition should be integrated into programmes of relevant research institutions Key strategies Collaborate closely with researchers to identify and carry out action oriented research on food and nutrition issues. Ensure that appropriate nutrition issues are incorporated into national surveys Collaborate closely with researchers in conducting nutrition surveys 21 3.8 Specific Objective 8: Coordination of Nutrition Activities Policy: Nutrition Division of the Ministry of Health and Sanitation should ensure that activities to address nutrition issues are reflected in plans of other programmes and implemented in a multisectoral, coordinated manner Key strategies Develop and implement appropriate structures to implement and coordinate nutrition activities Strengthen linkages among key stakeholders to enhance effective implementation of nutritional activities including food security 22 CHAPTER 4: INSTITUTIONAL ARRANGEMENTS 4.0 Implementation Mechanism for the Sierra Leone National Food and Nutrition Policy Food and Nutrition security issues are multifaceted in nature and therefore implementation of activities shall be undertaken in a multi-sectoral way. For this reason, there is a need for a coordinating body at the national level. Membership of this task force comprises representatives from the Ministry of Health and Sanitation, United Nations agencies and NGOs with expertise in nutrition. The Nutrition Technical Task Force should be transformed into a Nutrition Technical Committee; its membership should be expanded and it should submit a report of its activities through the Reproductive and Child Health (RCH) Directorate to the Health Coordinating Committee chaired by the Chief Medical Officer. A similar structure should be established at the district level. 4.1 Functions of Nutrition Technical Committee Serve as an advisory body to provide technical advice on all technical issues relating to nutrition in the country. Identify nutritional problems and provide strategies to solve or alleviate such problems in a coordinated manner. Serve as a supervisory and coordinating body for all nutrition activities carried out in the country. Provide a forum for networking and collaboration among stakeholders on nutrition matters Mobilize resources for food and nutrition interventions in the country Monitor the implementation of the Food and Nutrition Policy 4.2 Functions of Nutrition Technical Committee at district level Advise the District Health Management Team on food and nutrition issues Collate, analyse and disseminate data on the status of food and nutrition in their respective areas; Advocate and ensure that food and nutrition issues are incorporated in the district development plans; and Co-ordinate activities of all government institutions, Non Governmental Organisations (NGOs), private sector and Community Based Organisations (CBOs) involved in food and nutrition programmes in their areas of jurisdiction 23 4.3 Functions of MOHS The Food and Nutrition Programme Contribute to the promotion of food and nutrition security at all levels in the country. Provide technical guidelines and ensure integration of nutrition considerations into national plans, programmes and projects of the Ministry of Health and Sanitation in particular and other institutions, sectors and organizations involved in food and nutrition activities. Provide a secretariat for effective and efficient functioning of the Nutrition Technical Committee Mobilize resources for the effective execution of the Food and Nutrition Policy and Nutrition action plan. Work in close collaboration with all persons, institutions, sectors and organizations involved in food and nutrition activities. Promote and make the population aware of food and nutrition issues. Promote research on food and nutrition. Serve as an advisory body to the Government on issues relating to food and nutrition. Carry out such other functions as the Minister may assign to it, from time to time. 4.4 Functions of other Line Ministries MAFFS, MEST, MOFED, MFMR and MOTI Ensure adequate provision of human, financial and material resources for all nutrition related activities in their ministries. Ensure that nutrition considerations are integrated in the various plans and programmes of the ministries. Participate in the implementation of nutrition programme activities under their ministries. 24 4.5 UN Agencies Provide technical support and mobilize funding to support nutrition programmes in the country. Assist in the implementation, monitoring and evaluation of nutrition programmes 4.6 International NGOs Provide technical support and funding for nutrition activities Assist in the implementation, monitoring and evaluation of nutrition programmes. Engage in sensitization activities at community level 4.7 Local NGOs and CBOs Collaborate with district nutrition technical committees for effective implementation and monitoring of nutrition programmes in the field. 4.8 Private Sector Collaborate with the different sectors in programme implementation. Undertake fund raising to support programme activities 4.9 Funding The funds for implementing the activities of the policy shall consist of: Money from the Government consolidated funds; and Grants and/or donations from the Government and other sources. 25 5.0 RELATED DOCUMENTS The following key documents shall be reviewed when using the Food and Nutrition policy: Agenda for Change/PRSP11 Millennium Development Goals Progress Report 2010 Vision 2025 National Strategic Health Plan 2010 - 2015 RCH Plan 2008 - 2010 National HIV strategic Plan 2011 - 2015 Education sector Plan-nutrition education in schools 2007 -2015 Joint Vision for Sierra Leone of the United Nations’ Family 2009 National TB Policy 2008 -2012 Smallholder Commercialization Programme Investment Plan 2010 Sierra Leone National Gender Strategic Plan 2010 - 2013 Sierra Leone Youth Policy 2003 Convention on the Rights of the Child 1989 African Chapter on Child’s Convention 1999 Convention on Elimination of Discrimination Against Women (CEDAW)