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Nutrition Plan of Action - Puntland 1 of 46

Puntland Costed Plan of Action for Nutrition 2013-2016

By Andi Kendle, Consultant for UNICEF Somalia, and the Puntland Nutrition Stakeholders

Funded by the Joint Health and Nutrition Programme


Table of Contents Acronyms ............................................................................................................................ 3

Introduction ........................................................................................................................ 5

Methodology and Process ................................................................................................. 6

Plan of Action ..................................................................................................................... 7

A. Review of Guiding Documents .................................................................................. 7

B. Development of Activities and Tasks ........................................................................ 8

C. Selection of Criteria for Validation of Priority Nutrition Interventions ..................... 8

D. Review of the PoA ................................................................................................... 10

E. Validation and Prioritisation of Broad Interventions ............................................. 10

F. Development of Funding Scenarios ........................................................................ 12

G. Development of a Results Framework.................................................................... 15

H. Definition of a Timeline for Activities ..................................................................... 16

I. Initial Costing of the PoA ........................................................................................ 16

J. Final Review and Validation ................................................................................... 16

K. Management Arrangements .................................................................................. 18

L. Implementation Arrangements .............................................................................. 18

M. Monitoring Modalities ............................................................................................ 19

Plan of Action Components ............................................................................................. 20

Cost for the Plan of Action ............................................................................................... 20

Discussion & Conclusions .............................................................................................. 21

Limitations .................................................................................................................... 22

Annex 1: Participating organisations in the development of the Nutrition PoA ........... 30

Annex 2: Puntland Activities Matrix (PLAM) ................................................................... 30

Annex 3: Puntland Results Framework ........................................................................... 31


Acronyms AM Acute Malnutrition ANC Antenatal Care ART Anti-retroviral Therapy/Treatment BB1 Building Block 1 (etc.) BMS Breast Milk Substitutes BNSP Basic Nutrition Services Package BSFP Blanket Supplementary Feeding Programme CB Community based CBHW Community Based Health Worker CHCs Community Health Committees CHDs Child Health Days Code Code of Marketing for Breast Milk Substitutes EPHS Essential Package of Health Services EPI Expanded Programme of Immunisations EPRP Emergency Preparedness and Response Plans FSNAU Food Security and Nutrition Analysis Unit GAM Global Acute Malnutrition GAVI HSS Global Alliance for Vaccines and Immunisations – Health System

Strengthening HC Health Centre HEI Higher Education Institutes/Institutions HF Health Facility HMIS Health Management Information System HR Human Resource HSC Health Sector Committee HSSP Health Sector Strategic Plan IDP Internally Displaced Population IEC Information Education and Communication IFA Iron Folate IMAM Integrated Management of Acute Malnutrition IPC Inter-personal communication IYCF Infant and Young Child Feeding JAR Joint Annual Review JHNP Joint Health and Nutrition Programme KAP Knowledge Attitudes and Practices L&M Leadership and Management MCHN Maternal and Child Health and Nutrition Programme M&E Monitoring and Evaluation MMNs Multiple Micronutrient Supplements MND Micronutrient Deficiencies MNPs Micronutrient Powders MOH Ministry of Health


MSG Mother Support Groups NAEC Nutrition Assessment, Education and Counselling NHHP Nutrition, Health and Hygiene Promotion NIDs National Immunisation Days NWG Nutrition Working Group OTP Out-patient Therapeutic Programme PoA Costed Plan of Action for Nutrition PHC Primary Health Care PLAM Puntland Activities Matrix PLHIV/TB People Living with HIV or TB PLWs Pregnant and Lactating Women PNC Post-Natal Care RF Results Framework RHC Referral Health Centre S1, 2 or 3 Scenario 1, 2 or 3 SAM Severe Acute Malnutrition SC Stabilisation Centre SFP Supplementary Feeding Programme TOT Training of Trainers/Trainers of Trainers TSFP Targeted Supplementary Feeding Programme U2s or U5s Children under 2 years old or under 5 years old UNICEF United Nations Children’s Fund WASH Water, Sanitation, Hygiene WFP World Food Programme WHO World Health Organisation


Introduction Despite Somalia’s reputation as one of the worst countries in the world regarding the nutrition situation, significant advances have been made over recent years to improve the situation. These advances are marked by substantial availability of nutrition services for the management of acute malnutrition as well as Infant, Young Child and Maternal Feeding and Care Practices throughout much of the country as well as the development of a Nutrition Strategy and an IYCF Strategy and Action Plan. Overall, the profile of nutrition has been elevated and it is well recognised by the health authorities as an important area for integrated action. While acknowledging these advances, nutrition is still a major problem in Somalia, with prevalence of acute malnutrition consistently above WHO thresholds, high levels of micronutrient deficiencies and extremely poor infant and young child feeding practices. This situation contributes substantially to high morbidity, mortality and overall disease burden in Puntland. Programmes have largely remained emergency-oriented, looking more towards the management of the situation as opposed to development of coordinated systems to encompass both preventative and treatment components to achieve more sustainable solutions to the problems. As such, while the IYCF strategy has attained some forward momentum, the Nutrition Strategy has remained largely unimplemented since it was produced. Amidst this backdrop, national authorities and the development partners have begun to address some of the foundational issues that exist. This is evidenced by the considerable work that has begun on strengthening the overall health system and to plan for national coverage of health and nutrition services to the population. Through the development of the Essential Package of Health Services, the Joint Health and Nutrition Programme, and more recently, the Health Sector Strategic Plan, the systems are gradually being planned and put in place to ensure that the health authorities are in the position to steward health and nutrition programmes and that all efforts work collectively towards improved health and nutrition for the Puntland population. Simultaneously, the 2013-2015 Consolidated Appeal Process ensures that humanitarian and early recovery remain in focus while system strengthening gain momentum. This Nutrition Plan of Action is part of this larger process. It has been funded by the Joint Health and Nutrition Programme and is an effort to ensure that a) nutrition activities are well coordinated and well integrated into health services, and that b) programmes are pursued in a strategic, prioritised and conscious manner to achieve improved maternal and child health and nutrition. The 4-year Costed Plan of Action for Nutrition should inform programme planning, budget forecasting, resource allocation and impact analyses for the sector. It should articulate an agreed set of sector priorities, the cost of implementing those priorities and the way in which they will be implemented.


Methodology and Process The development of the 4-year Costed Plan of Action for Nutrition spanned a period of several months, from December 2012 through May 2013, including multiple sessions and workshops. The process was designed to attain the highest level of participation and ownership by all of the nutrition stakeholders, with the Ministry of Health taking a leading role and UNICEF providing a consultant to facilitate and consolidate its development. Initially, discussions were held between the Ministry of Health and UNICEF to define how the process would be carried out. This was held on 12 December 2012 in Garowe. It was decided that consultations would be held with a wide group of nutrition stakeholders to bring in as many perspectives as possible, followed by more detailed work by a smaller group of stakeholders. The first consultation workshop was carried out over 4 days, from 9-12 January 2013, at the Ministry of Health in Garowe. The workshop was attended by 21 participants on the first two days and 11 participants on the latter two days, including the following stakeholders: Ministry of Health with representatives from Nutrition, Primary Health Care, GAVI HSS, EPI, HMIS, the Coordination Office and the Director General’s Office; Ministry of Women’s Development and Family Affairs; UNICEF; WFP; WHO; Save the Children; Relief International; Care; Somali Red Crescent Society; Merlin; Agency for Peace and Development; Horn Alliance Relief And Development and World Vision International. Since the workshop coincided with the analysis of the bi-annual Nutrition and Food Security surveys, the FSNAU Puntland team was unable to attend the workshop; however, over the following two weeks, additional meetings were held with them to obtain their inputs into the PoA. Annex 1 provides details of organisations that participated in each workshop. The workshop focused on: a) reviewing strategic documents, and b) developing concrete activities and tasks to implement the Nutrition and IYCF Strategies. Following the workshop, the information was processed and synthesised into an excel database to be used as a working draft of the PoA. In addition to capturing the content of the workshop, the database categorised each activity and task into one of the health system building blocks, with links to other building blocks and functions. This database was the precursor of the final Puntland Activities Matrix (PLAM), which is available in Annex 2. The second consultation workshop took place over 5 days from 2-6 March 2013. The same organisations participated as in the first workshop, although some of the representatives were different, with an attendance of 15-19 people daily. The workshop focused on: a) validating and setting priorities, b) developing funding scenarios, c) developing a results framework through the establishment of baselines, plan targets and annual milestones, and d) reviewing the activity-level plan and setting timeframes for each activity.


After this second workshop, the Plan of Action, which had maintained the same structure as the Nutrition Strategy up to that point, was converted to reflect the health sector strategic planning documents. In other words, where the Nutrition Strategy is organised around Outcome Areas, the Plan was reorganised to reflect functional areas of health systems, or building blocks. Figure 1 describes this conversion from Outcome Area to Building Blocks. It is expected that this adaptation will allow for greater integration of nutrition into health planning processes including annual budgeting and resource allocation as well as greater understanding by all of the depth and breadth of programming that is required to achieve true integration. Figure 1: Conversion of the Plan of Action from Outcome Areas to Building Blocks

Once the conversion process was complete, initial costs and quantities were estimated and entered into the PLAM in preparation for the final workshop. This allowed for initial plan costs to be derived that would undergo review during the validation and costing workshop. Similarly to all other stages of the development of the Plan of Action, a consultative approach was employed with the participation of UNICEF, WFP, FSNAU and the Nutrition Cluster. It took place from 24 April – 3 May in Nairobi with the inputs from the Puntland team as the basis for the work. Finally, a validation and costing workshop was carried out from 20-22 May 2013 at the Ministry of Health in Garowe. The same organisations were represented during this workshop as the previous two, with a daily attendance of 10-14 people. The workshop focused on: a) reviewing the converted Plan at both intervention and activity level, b) refining unit costs, quantities and timing of activities in the Plan, c) analysing the costed scenarios and selecting the preferred one, and finally, d) planning the way forward for validation and endorsement of the Costed Plan of Action for Nutrition. The next section describes each step of the development process in more detail. Plan of Action A. Review of Guiding Documents

Nutrition Strategy Outcome Areas 1. Manage all types of malnutrition 2. Nutrition Information 3. Infant, Young Child and Maternal

Feeding and Care Practices 4. Prevention of Micronutrient

Deficiencies 5. Mainstreaming nutrition with

other sectors 6. Capacity strengthening

Health System Building Blocks 1. Leadership, Governance,

Management 2. Human Resources 3. Service Delivery 4. Financing 5. Supplies 6. Nutrition and Health Information


The first workshop undertook a review of the health and nutrition strategic documents that relate to and influence nutrition programming, including the following key documents:

Puntland Health Policy Framework, 2012-2017

Puntland Health Sector Strategic Plan (HSSP) - draft

Essential Package of Health Services (EPHS)

Joint Health and Nutrition Programme (JHNP)

Somalia Nutrition Strategy, 2011-2013

Infant and Young Child Feeding Strategy and Plan of Action, 2012-2016

Basic Nutrition Services Package (BNSP)

WHO’s Framework of 6 building blocks for Health System Strengthening

While overviews were provided of all of these documents, more emphasis was placed on the documents specific to nutrition as these would be the foundation for the Nutrition Plan of Action and, therefore, for the activities carried out in the workshop. Additionally, special attention was also given to the HSSP and the EPHS, as these two documents define the strategic direction that the health system intends to pursue over the coming 4 years. Due to the important link between the Health Sector Strategic Plan and the Nutrition Plan of Action, the consultation workshop was held simultaneously with the second phase of the HSSP development process. This enabled increased interaction and inputs for the development of both Plans. B. Development of Activities and Tasks Once the strategic documents were reviewed, the workshop focused on the outcomes, outputs and activities from the Nutrition and IYCF Strategies. These were used as the basis for the Plan of Action and closely examined each Outcome Area of the Nutrition Strategy individually. This process excluded Outcome Area 5, Mainstreaming Nutrition into Health and Other Sectors, since it would require special attention only after all of the other Outcome Areas were addressed; this is detailed in section C, below. Each of the existing activities was broken down into more concrete and concise activities and tasks. The group carefully considered how they would like to carry out these broader activities and sometimes included fine details, including who should be responsible for the activity and who should be involved. C. Selection of Criteria for Validation of Priority Nutrition Interventions At the end of the first workshop, the group brainstormed on potential criteria to use for validation of priority interventions, an exercise that would be carried out during the second consultation workshop.


Following on from the brainstorming session, a simple prioritisation matrix was employed to select the final criteria for validation of priorities outlined in the Nutrition and IYCF Strategies. Out of 12 criteria chosen during the brainstorming session, four were selected for the final validation process:

life-saving

magnitude of the problem/aligned with needs

evidence-based

cost-effective/value for money The matrix for the selection of criteria can be found below in Table 1. Table 1: Selection of Criteria for Validation of Priority Nutrition Interventions Review of the PoA: Initially, the group reviewed the working draft of the PoA, verifying that it captured the ideas expressed in the first workshop and adjusted it to ensure that they were comprehensive, relevant and appropriate. Special attention was given to two topics:

Outcome Area 5, Mainstreaming Nutrition into Health and Other Sectors: In order to ensure that the multi-sectoral nature of nutrition was well captured in the activities within the PoA, a discussion on the conceptual framework was held and a brainstorming on the relationships between nutrition and other sectors. It was concluded with group work that defined concrete activities that could be included in the PoA to ensure that these multi-sectoral linkages are addressed.

Community level component of nutrition interventions: Throughout the Nutrition and IYCF strategies, there are many activities that involve community level volunteers or staff. Additionally, many other sectors also utilise this type of cadre of staff for implementation of their activities. Considering that the HSSP and the EPHS roll-out over the coming four years will focus more on strengthening the facility-based health system, a special session was held to acknowledge the importance of interventions at this level for nutrition and its underlying causes. Therefore, this session aimed to explore what activities are currently being carried out at a community level, how and who are carrying them out. Finally, it was agreed that these community level activities need to be well articulated, coordinated, realistic, feasible and integrated to not overburden this highly valuable but lowly qualified and little recognised cadre of staff.

Note: During the process of brainstorming and selecting criteria for validation of priorities, numerous criteria were repeatedly emphasised as important to the group. These are essential characteristics of programmes and projects which should be considered during the design and implementation phase, not the validation of interventions phase; therefore, they were withdrawn from the process. However, these criteria remain a highly relevant and important component of this PoA.

a. Sustainability b. Involvement of the community and other stakeholders c. Equity


When designing, selecting or implementing projects within this Plan of Action, these characteristics and criteria should be kept in mind and used as a cornerstone for programming. D. Review of the PoA At the start of the second workshop, the group reviewed the working draft of the PoA, verifying that it captured the ideas expressed in the first workshop and adjusted it to ensure that the contents were comprehensive, relevant and appropriate. Special sessions were held to concentrate on two topics:

Outcome Area 5, Mainstreaming Nutrition into Health and Other Sectors: In order to ensure that the multi-sectoral nature of nutrition was well captured in the activities within the PoA, a discussion on the conceptual framework was held and the group brainstormed on the relationships between nutrition and other sectors. After brainstorming, group work defined concrete activities that could be included in the PoA to ensure that these multi-sectoral linkages would be addressed.

Community component of nutrition interventions: Throughout the Nutrition and IYCF strategies, there are many activities that involve community based volunteers or staff. Additionally, many other sectors also utilise the same, or a similar, cadre of staff for implementation of their activities.

Considering that the HSSP and the EPHS roll-out over the coming four years will focus more on strengthening the facility-based health system, a special session was held to acknowledge the importance of interventions at this level for nutrition and its underlying causes. Therefore, this session aimed to explore a) what activities are currently being carried out at a community level, b) how they are being carried out, and c) who is carrying them out. Finally, it was agreed that these community level activities need to be well articulated, coordinated, realistic, feasible and integrated to not overburden this highly valuable, but lowly qualified and little recognised cadre of staff.

E. Validation and Prioritisation of Broad Interventions The Nutrition and IYCF Strategies were developed in 2010 and 2011, respectively. As strategy documents, they reflected the existing priorities of the nutrition stakeholders at the time of their development. Therefore, this session aimed to validate whether the priorities expressed in these strategies still reflects the current situation. Using the criteria selected and detailed in Section C above, each broad intervention was scored on a scale of 1 to 10, with 1 being the least applicable and 10 being the most applicable to that intervention. The scores were then tallied, with a maximum attainable score of 40 points. Any intervention with a score of 50% or more was deemed validated as priority and those with less than 50% were deemed not priority for this PoA over the coming 4


years. Through this process, all interventions were validated as priority for the PoA, with the exclusion of only two interventions:

a. Food Vehicle Fortification: while it was acknowledged that this intervention can be very cost-effective internationally and that it would address a great problem in Puntland, the cost-effectiveness was strongly questioned given the current situation in the country. There was interest to explore possibilities for food vehicle fortification in the subsequent Nutrition PoA.

b. Legislation on Processed Complementary Foods: as an additional component to the Code of Marketing of Breast Milk Substitutes, it was highlighted that the availability of these products is very low and that very few families actually use them to feed their young children. Therefore, development and advocacy for legislation relating to these products was not considered to be aligned with the needs.

The scoring of all interventions is included in Table 2 below.


Table 2: Validation of priority interventions from the Nutrition & IYCF Strategies

F. Development of Funding Scenarios


While the prioritisation exercise explained above confirmed broad interventions that should remain a part of the PoA, some interventions were considered to be more essential than others, as demonstrated in the final scores. The process of developing funding scenarios allowed participants to define what type of interventions would be implemented in three different scenarios, 1) when there is limited funding, 2) when there is a medium level of funding, and finally, 3) when funds are not a limiting factor in programming. First, the group developed characteristics for each scenario, deciding in theory what types of interventions would be implemented in each scenario. These are outlined in Table 3 below. Table 3: Definition of funding scenarios and types of interventions for each

Scenario 1 Scenario 2 Scenario 3

Assumptions/Environment - Limited funds - Limited HR capacity

Assumptions/Environment - Medium funds - Limited HR capacity

Assumptions/Environment - High funds - Slightly more HR capacity

Only prioritised interventions

Critical areas prioritised

High need (based on evidence of the need)

Targets most vulnerable groups

Life-saving

Evidenced-based prevention activities

Shorter duration

Cost-effective interventions (Note: life-saving is prioritised over cost-effective)

Modified versions of services/intervention where essential but too costly

Prioritised system-building interventions

Surveys/surveillance for priority concerns, with basic programme M&E

Broader coverage of the population but still prioritised

Longer duration and takes longer to achieve

More activities and interventions

Targets vulnerable groups as well (not only most vulnerable)

More focus on quality of interventions, also increased M&E

BCC interventions

More focus on capacity strengthening

More systems-building interventions

Full coverage

Targets all

Increased research and evaluation, stronger M&E with deeper analysis

Community ownership activities

Increased focus on institutional capacity strengthening

Long-term activities

General infrastructure development (more towards the basic causes of malnutrition)

Once the group developed a clear definition for each funding scenario, each intervention was allocated to a scenario. This was a process with much debate until a


consensus was reached on when each intervention would be carried out. Table 4 details the outcome of this discussion. Interestingly, the group did not allocate any broad interventions to Scenario 3, the high resource environment; however, certain activities within an intervention would only be implemented when more funding would be available. Additionally, in a medium resource environment, the coverage of these interventions would be lower and more targeted than in a high resource situation. Table 4: Allocation of key interventions to scenarios

Scenario 1 – low resource environment IMAM Services

Treatment of Micronutrient Deficiencies - Therapeutic Zinc for treatment of diarrhoea in children

Food-based Interventions - Blanket Supplementary Feeding – where and when the situation is critical

IYCF - Community-based individual counselling - Community-based mother-to-mother support groups

Prevention of Micronutrient Deficiencies - Vitamin A for children under 5 years and post-partum women - Iron-Folate for pregnant and lactating women - Deworming of children under 5 years

Promotion of BNSP - Community-based promotion of BNSP

Scenario 2 – medium resource environment All of the interventions included in Scenario 1, plus the following:

Food-based Interventions - Maternal & Child Health and Nutrition - Institutional Feeding of TB and HIV/AIDS patients

IYCF - Legislation and promotion for the Code of Marketing of Breast Milk Substitutes - Legislation and promotion regarding Maternity Protection and Care of Young Children - Facility-based IYCF counselling - Facility-based IYCF mother support groups

Prevention of Micronutrient Deficiencies - Multiple micronutrient supplements for pregnant and lactating women - Home fortification products - Deworming of children in schools

Promotion of BNSP - Facility-based promotion of BNSP - Community ownership for BNSP

- Communication for Development

Scenario 3 – high resource environment All interventions included in Scenario 1 and 2, with increased coverage aims to target all


G. Development of a Results Framework With clarity on the priority interventions for the Plan, it was necessary to establish the magnitude, or the desired reach, for the Plan. Normally, this will depend on both the needs as well as the resources available within a country; however, for Puntland, as the nutritional needs are well documented and are known to be high, this process only considered differences in resources available, as explained above through the funding scenarios. For each broad intervention area, the group needed to establish the current status of programming, or baselines, as well as what they want to achieve over the duration of the plan, or coverage targets. As coverage targets depend on the resource environment, as explained above, different coverage targets were developed for each scenario. As part of this process, the group also established annual milestones to more realistically enable achievement of the plan as well as to be able to monitor progress towards the overall plan objectives. Annex 3 displays this Results Framework, including baselines, coverage targets and annual milestones for each intervention, indicating the scenario when the target differs. As the Plan of Action has been constructed to correspond with the HSSP, the Results Framework is also structured according to the building blocks for health systems, or Strategies. There are a few objectives for each Strategy that have been adapted from the HSSP, which are followed by nutrition specific baselines, targets, milestones and indicators; the service delivery Strategy and Objectives have been further subdivided into broad nutrition intervention areas. Results Framework sections include:

Building Block 1: Leadership, Governance and Management for Nutrition

Building Block 2: Human Resources for Health and Nutrition

Building Block 3: Service Delivery o IMAM Services o Food-based Interventions – MCHN, BSFP, Institutional Feeding o Treatment of Micronutrient Deficiencies, including use of Zinc o Prevention of Micronutrient Deficiencies o IYCF services o Promotion of BNSP services o Community Ownership for BNSP o Communication for Development

Building Block 4: Financing

Building Block 5: Supply of Medicines and Consumables

Building Block 6: Health and Nutrition Information and Research


H. Definition of a Timeline for Activities Finally, the last stage of the second workshop was to establish when different activities would be carried out over the period of the PoA. This information allows for a yearly costing of the PoA in addition to facilitating the annual planning process. As this PoA has a great number of detailed activities, this timeline cannot be included here but can be found in the PLAM database, in Annex 2. I. Initial Costing of the PoA Once the second workshop was complete and the Plan had been converted to reflect the building blocks for health systems, the process of establishing initial costs and quantities was started. This process was carried out as a series of consultations with high level nutrition management staff of various organisations, including UNICEF, WFP, FSNAU and the Nutrition Cluster. These actors started with a review of the Plan both to familiarize themselves with the contents of the Plan as well as to incorporate adjustments to ensure the relevance, cohesion and comprehensiveness of the activities and the structure. Once the structure and the contents of the Plan were fine-tuned and agreed, the initial costs and units had to be established. Various sources of information were used for this process, including a) a collection of estimated unit costs of common inputs from organisations participating in the workshops in Puntland, b) a compilation of average costs from UNICEF, WFP, and FSNAU, and c) existing knowledge of costs to operate in Puntland. Using the notes from the first and second workshops as well as the facilitator’s knowledge of each activity, the participants were able to appropriately consider and set costs for each activity on a line by line basis. The next step was to establish the quantities for each activity, carefully accounting for each year and each scenario. The results framework acted as the basis for this exercise, as it clearly outlined annual milestones and plan targets for each year and funding scenario, allowing quantities to be estimated for each activity. Again, notes from the first and second workshops for each specific activity as well as existing knowledge of programming aided in this process. J. Final Review and Validation With the converted PLAM, the Results Framework and these initial costing tables, a final workshop was held in order to carry out a final review of this work, to validate the outputs and to establish the way forward for endorsement of the PoA.


Review of the Results Framework: While the participants had developed the first draft of the Results Framework during the second workshop, it had undergone various stages of revision since that time. This was an opportunity to explore the latest version of the document, which incorporated initial drafts for each building block area, and to adapt it accordingly.

Allocation of costs to the Programmatic Areas and RF Objectives: While the initial costing was complete at the beginning of the workshop, the summary tables were not yet finished. Therefore, during the workshop, the group went through the process of dedicating activities and costs to both the Programmatic Areas as well as to the Results Framework Strategies. This step allowed the participants to gain a greater understanding of the link between the listed activities, with their respective quantities and costs, and the summary tables.

Review of the PLAM, Costs and Quantities: As this workshop was the first opportunity for the team to see the Activities Matrix converted to the Building Blocks, an initial briefing was given on how the matrix works, what it contains and how it relates to the Results Framework. Then, the facilitator guided the group through numerous outstanding questions and issues, particularly in terms of quantities, which the group resolved. Finally, the participants were given the PLAM to review individually in order to further familiarise themselves with the database, examining in depth their organisation’s specific area of interest. This served as a means to highlight and then discuss any remaining issues or concerns.

Review and refinement of the costed Plan of Action: Once all of the unit costs and quantities were understood and reviewed, the group was presented with the resulting cost for the plan. This was the moment of truth when the group’s aspirations had been translated into a cost. The total cost for the PoA seemed quite ambitious; however, as the summary costing tables only emerged on the last day of the workshop, the group planned a subsequent meeting to discuss how it could be refined realistically. This meeting was incorporated into the way forward for endorsement of the Plan (outlined below).

Way forward for endorsement of the PoA: In addition to the above-mentioned meeting, the group discussed the steps required in order to reach the point of plan endorsement. This included the following points:

o The full PoA must be shared and reviewed by all of the participating partners, from their senior management through to programme implementers

o As the PoA emphasises the multi-sectoral nature of nutrition and encompasses many activities across sectors, it is important to obtain input and feedback from a wide range of actors, including but not limited to the following: Ministry of Health Department Officers, Ministry of Education, Ministry of Women, Ministry of Agriculture, Puntland Aids Commission,


Puntland State Agency for Water, Energy and Natural Resources (PASWEN), Humanitarian Affairs and Disaster Management Agency (HADMA), Ministry of Finance, Ministry of Planning, Members of Parliament and NGOs and UN agencies. These high level meetings/consultations will be led by the Ministry of Health with support from UNICEF.

o A final brief review should be carried out after all input has been incorporated from the above stakeholders. A limited timeframe should be allocated for this final review.

o Presentation of the PoA during the Health Sector Coordination meeting. o A final endorsement event should be held jointly with the other zones of

Somalia. K. Management Arrangements During the final workshop, time was allocated to discuss and establish management and implementation arrangements for the PoA. As the Nutrition PoA is a component of the HSSP, it was felt that the arrangements for HSSP should also encompass those for Nutrition. Therefore, a coordination structure should be established in line with the HSSP management arrangements, whereby nutrition should be represented on the Zonal Health and Nutrition Coordination Committee. The nutrition specific venue for coordination will be the Nutrition Working Group that will feed into that Zonal Health and Nutrition Coordination Committee; this working group, which is currently using the cluster approach should gradually shift to a sector approach. Beneath the Nutrition Working Group, there will be task forces/sub-working groups such as the IYCF task force, amongst others that will be established according to the needs. Each of these committees, working groups and task forces should have clearly defined roles and responsibilities that are articulated through Terms of Reference. L. Implementation Arrangements Similarly to the HSSP, it was agreed that various modalities would be used to implement the Nutrition PoA. An implementation unit would be established within the Ministry of Health, as part of the HSSP, which would oversee the implementation of the Nutrition PoA. During the four years of the plan, it is foreseen that contracting in would be the mainstay of service delivery for the Plan, with some contracting out, where necessary. Selection of service providers will be done through two mechanisms, 1) sole sourcing/pre-selection, and 2) competitive bidding process. The first acknowledges that there are many service providers already working and these contracts can be maintained. The competitive bidding process incorporates a call for proposals or expressions of interest, a screening of applicants and finally the selection. It was agreed that this process would be undertaken by a selection committee, led by the Ministry of Health with representatives from UN agencies as well as NGOs, to ensure appropriate transparency. In the first half of the plan, it is expected that the legal contracting aspects


will be maintained as they are currently, however, with a shift towards tripartite agreements over time. M. Monitoring Modalities The participants felt that monitoring of the Plan of Action should be considered in two phases. Immediately, core indicators were established for each strategy and objective. These indicators as well as their source and the person responsible are one component of the Results Framework in Annex 3; however, for ease, the core indicators are also displayed here in Table 5. As a more comprehensive process, a full monitoring and evaluation framework for the PoA should be developed. This M&E framework should incorporate mechanisms to monitor inputs, process, output, outcome and impact, including a mid-term and a final evaluation of the PoA. Annual reviews should be carried out in order to adjust the priorities and the targets. Regular and continuous monitoring and supervision should be carried out for the whole plan, incorporating both individual and joint monitoring and supervision. It was strongly felt that monitoring is a responsibility for all – the MOH as well as all nutrition partners. Table 5: Core Indicators

Indicators - Puntland

S1: Leadership, Governance and Management for Nutrition

Indicator 1.1: Number of nutrition related Legal Acts, Policies, Strategies and Plans produced as specified in the PoA

Indicator 1.2a: Number of national and regional coordination structures in place and functional

Indicator 1.2b: Percentage of partner organisations with regular attendance in coordination meetings (at 90% of the meetings)

Indicator 1.3: Number of senior nutrition managers trained in line with L&M Programme

S2: Human Resources for Health and Nutrition

Indicator 2.1: Percentage of staff under contract and receiving an annual appraisal at the end of the year

Indicator 2.2: Number of new graduates from nutrition training programmes

S3: Service Delivery

Indicator 3.1a: Percent of EPHS facilities implementing BNSP Services

Indicator 3.1b: Percentage of PLWs within the health facility catchment population that receive IYCF counselling services

Indicator 3.2a: Number of communities with community based health workers implementing nutrition activities

Indicator 3.2b: Percent of women with appropriate practice of early initiation of breastfeeding

S4: Financing

Indicator 4.1: Proportion of national budget allocated for nutrition

S5: Supply


Indicator 5.1: Percentage of HFs with stock-outs of key nutrition products (RUTF, RUSF, amoxicillin, MMNs, MNPs) less than 10% of total supply months in all of the regions

S6: Health and Nutrition Information and Research

Indicator 6.1a: Number of health facilities and nutrition services providing timely, complete and accurate nutrition reports

Indicator 6.1b: Annual IMAM coverage surveys are conducted systematically for at least 4 regions

Indicator 6.2: Availability of a long-term research and survey plan

Plan of Action Components Generally, the costed Plan of Action includes information at two levels, the intervention level and activity level, and is made up of 2 key components:

This document summarises the process and the rationale behind the PoA and its development. It also includes all intervention level information, most importantly, the Results Framework (Annex 3) as well as the summary costing tables and graphs.

The PoA database, also called the Puntland Activities Matrix (PLAM), includes all activity level information. The PLAM is a tool that can be used in many ways as it contains 6 levels of information and has been designed to be able to aggregate or disaggregate information as needed. It is also possible to filter activities in various ways, i.e. by the programmatic area, by strategy, or by year. These features allows the plan to be useful for a multitude of purposes, whether at strategic level or operational level. As the summary costing tables and graphs are a component of the PLAM, as changes are made to the activities, these tools will automatically be updated to reflect the changes.

Cost for the Plan of Action The costs for the PoA are displayed in Tables 6 by Strategy, in Table 7 by Programmatic Area and in Table 8 by Strategy and Programmatic Area. Each table has a costing per year as well as per funding scenario, whereby Scenario 1 denotes a low financing environment, Scenario 2 a medium financing setting and Scenario 3 a situation with high financial resources available. The differences between these three summary tables are explained in more detail here:

A. By Strategy or Building Block (BB): In Table 6, all costs are strictly allocated to each Strategy of the HSSP based on the specific activity, regardless of the intervention area. As an example, community-based IYCF counselling would be broken down into different activity groups: coordination activities and the development of the standardised materials would be allocated to BB1, incentives for the


community-based volunteers allocated to BB2, the printing of the IEC materials for use in these activities goes to BB5, it’s monitoring or evaluation allocated to BB6, leaving simply specific operational costs for the actual service delivery for BB3.

B. By Programmatic Area: In Table 7, all costs are assigned to a specific programmatic area wherever possible. In this case, all functions specific to an intervention area are assigned together, leaving only the most general of activities to be allocated to a few cross-cutting categories. Using the above example, all of the costs related to community-based IYCF counselling would be allocated to the IYCF Services category; however, an activity such as reviewing and adapting the nutrition curriculum of pre-service training institutions, which includes IYCF as well as various other intervention areas, would be allocated as a Systems cost.

C. By Results Framework Strategy and Programmatic Area: In Table 8, costs are

divided according to the strategy of the results framework, as in A above, as well as the programmatic area that the activity relates to, as in B above, therefore, combining the above two tables. In this case, activities are initially allocated to the building block, but for BB3 Service Delivery, the costs are further divided between the intervention areas. Once again, only the operational costs of an intervention are considered under BB3, while all other costs such as supply or training have been allocated to their respective building blocks.

These three respective summary tables, with costs by scenario and by year, can be found in Table 6, 7 and 8, as well as graphs with breakdown of costs for each scenario. Discussion & Conclusions The Costed Plan of Action for Nutrition in Somaliland for Scenario 1 has an annual estimated expenditure of $5.5-6.5 million, totalling approximately $24.5 million over the four years. As a cost per capita, this works out to approximately $22 per person, based on the population estimates available (see Limitations Section below). For Scenario 2, the total cost for the PoA is approximately $56 million, with a breakdown of between $12.5 and $15 million per year. This equates to a per capita expenditure of roughly $51 per person. Scenario 3, the most ambitious of the scenarios, works out to $99.5 million for the four years, or $21-28 million per year. In other words, this plan would cost about $91 per capita.


While the cost estimated seems rather high, it must be noted that the bulk of the expenditure for all three of these scenarios is largely attributable to two interventions:

a. IMAM services, an inherently costly programme in part due to the importation of specialised products, and

b. MCHN services, for similar reasons as IMAM with the addition of its large scale as it targets all pregnant and lactating women and young children.

While the graphs below Table 7, the programmatic costing table, demonstrate the high proportion of the funds required for the plan dedicated to IMAM and MCHN programmes, on further investigation, in fact, IMAM service delivery and supplies account for 57%, 43% and 44% of the budget for Scenario 1, 2 and 3, respectively, while MCHN service delivery and supplies account for 0%, 25% and 18% of the plan for Scenario 1, 2 and 3. In other words, apart from IMAM and MCHN service delivery and supplies, the cost of the rest of the plan per year is $2.6 million, $4.5 million and $9.4 million respectively for each scenario. While some debate is likely necessary surrounding the value for money for each of these interventions, there are also some issues with the costs for these services that are further discussed in the Limitation Section below. Despite the potential issues that are mentioned in the Limitation Section, it must be acknowledged that IMAM services, which are largely curative in nature, are very costly. This brings to mind the idiom ‘prevention is better than cure.’ Prevention can certainly be less expensive. This raises the point that while curative programmes are undoubtedly indispensable, health and nutrition programmes must balance preventative and curative approaches. Naturally, that is where interventions like the MCHN programme come in, to prevent malnutrition, among other objectives. However, while preventative by design, the MCHN programme still heavily relies on specialised imported products causing the programme to be too costly and resource intensive to be sustainable. To tackle these difficult issues, community based strategies for prevention are an important approach that has been well incorporated into this plan – these types of preventive and sustainable approaches, when integrated and harmonised with other sectors, will achieve the greatest gains for the Somali population. Limitations As this is the first Costed Plan of Action for Nutrition within Puntland, there are various limitations that should be highlighted. These limitations are aspects that should be kept in mind during its use as well as aspects that should be improved upon during development of the subsequent PoA.

Cost estimates can be duplicative, due to the nature of programming in Somalia, whereby partners implement individual components of programmes, instead of fully integrated programmes. This is particularly important for the service delivery


component of IMAM and Food-based interventions which are cost-drivers for this plan. To demonstrate this more clearly, IMAM services can be taken as an example: IMAM programmes are often carried out by several organisations in one area, each one implementing a different component of the service; in this case, each component has dedicated staff for similar roles. When these services are integrated either within one organisation or, preferably, within the health services, vast cost savings can be achieved. At this stage, as cost estimates for the activities in this plan have been derived based on the current mechanisms of implementation, cost for fully integrated versions of these programmes are not readily available. However, with integrated programme planning amongst key partners and the MOH, costs for integrated service provision could be established and incorporated into the PoA. This will also enable a clearer joint vision of integration as a whole as well as phases that could be defined as intermediary milestones.

While every effort has been made to ensure that the activities costed inside this PoA are complementary to those within the HSSP and the EPHS roll-out plan, there may be some instances where duplication and overlap has occurred. For the most part, activities that appear to be duplicative have been included in this PoA to account for Nutrition’s contribution to that broader health activity. However, for nutrition supplies particularly, there is likely to be some duplication between the two plans, since some supplies were costed within the EPHS roll-out (Lot 3) and this PoA comprehensively included supplies by applying actual usage estimates to future expansion plans.

As explained in the above point, costs that are already incorporated into the EPHS and, therefore, the HSSP, have largely not been included here. This means that staff costs are largely omitted from this plan, except for where these staff are additional to those included in the EPHS. While these costs should be allocated to BB2 Human Resources, some are actually captured under BB3 Service Delivery.

Population estimates in Somalia are known to be inaccurate and contested; therefore, this PoA has avoided the use of populations as much as possible. However, UNDP 2005 population estimates with the 3% annual population growth were used for the derivation of costs per capita for each activity and the overall Plan. Therefore, there may be some difficulty in comparing the cost per capita for this PoA with those of other countries. As soon as more accurate and accepted population figures are available, these figures should be replaced in the formulas to obtain more appropriate and comparable costs per capita.


Table 6: Costing Summary Table per Strategy, by Scenario and by Year

2013 2014 2015 2016 2013 2014 2015 2016 2013 2014 2015 2016

Nutrition Plan of Action 5,583,388 6,436,739 6,233,084 6,216,418 24,469,629 12,620,068 13,968,660 14,604,554 15,053,933 56,247,216 21,046,738 24,136,519 26,402,511 27,978,457 99,564,225

StrategyStrategy 1 - Leadership, Gov & Management 192,373 302,823 147,373 145,923 788,493 284,648 386,923 217,173 219,473 1,108,218 284,773 400,023 229,273 233,223 1,147,293

A. Coordination & Partnership 84,000 102,200 92,500 92,500 371,200 99,250 130,650 115,300 120,300 465,500 99,350 138,200 122,650 127,650 487,850

B. Policy, Strategy & Guideline Dev 60,183 150,183 11,833 12,383 234,583 85,183 159,483 13,333 12,883 270,883 85,183 161,483 13,333 12,883 272,883

C. Resource & Material Development 4,050 3,400 2,000 - 9,450 19,350 8,750 6,100 2,450 36,650 19,350 11,200 6,550 4,450 41,550

D. Supervision, Monitoring & Support 37,600 37,600 37,600 37,600 150,400 73,600 73,600 73,600 73,600 294,400 73,600 73,600 73,600 73,600 294,400

E. Advocacy 6,540 9,440 3,440 3,440 22,860 7,265 14,440 8,840 10,240 40,785 7,290 15,540 13,140 14,640 50,610

Strategy 2 - Human Resources 657,293 896,350 863,050 913,550 3,330,243 803,076 1,219,600 1,299,900 1,317,000 4,639,576 1,002,576 1,574,600 1,668,000 1,752,100 5,997,276

F. Capacity Strengthening 335,593 446,450 397,450 322,950 1,502,443 470,876 703,400 657,900 499,400 2,331,576 647,876 954,600 910,100 752,600 3,265,176

G. Training 75,400 140,600 78,600 110,600 405,200 85,900 167,900 129,000 139,600 522,400 108,400 217,700 151,900 189,500 667,500

H. HR Management 246,300 309,300 387,000 480,000 1,422,600 246,300 348,300 513,000 678,000 1,785,600 246,300 402,300 606,000 810,000 2,064,600

Strategy 3 - Service Delivery 2,290,791 2,330,453 2,378,290 2,405,427 9,404,961 5,111,683 5,353,302 5,701,101 6,015,300 22,181,386 6,446,185 7,574,983 8,943,286 9,826,104 32,790,558

I. Health facility level 2,022,900 2,046,250 2,070,000 2,073,500 8,212,650 4,559,670 4,740,620 5,002,070 5,243,870 19,546,230 5,424,920 6,313,220 7,451,020 8,123,470 27,312,630

J. Community level 216,091 224,603 233,090 241,427 915,211 467,413 507,982 557,081 601,230 2,133,706 910,315 1,114,713 1,305,516 1,484,684 4,815,228

K. Community Sensitisation/ Mobilisation 51,800 59,600 75,200 90,500 277,100 84,600 104,700 141,950 170,200 501,450 110,950 147,050 186,750 217,950 662,700

Strategy 4 - Finance 3,600 15,600 3,600 3,600 26,400 3,600 15,600 3,600 3,600 26,400 3,600 30,600 3,600 3,600 41,400

O. Relates to Finances 3,600 15,600 3,600 3,600 26,400 3,600 15,600 3,600 3,600 26,400 3,600 30,600 3,600 3,600 41,400

Strategy 5 - Supply 2,220,611 2,390,093 2,355,551 2,273,998 9,240,252 5,998,340 6,326,315 6,485,560 6,596,640 25,406,855 12,890,884 13,882,393 14,586,131 15,245,510 56,604,918

L. Supplies (or related) 2,170,611 2,161,093 2,181,551 2,170,998 8,684,252 5,932,340 6,051,215 6,280,460 6,468,140 24,732,155 12,824,884 13,607,293 14,375,731 15,103,710 55,911,618

M. Materials & Resources 15,000 87,000 30,000 61,500 193,500 31,000 133,100 61,100 87,000 312,200 31,000 133,100 66,400 100,300 330,800

N. Infrastructure 35,000 142,000 144,000 41,500 362,500 35,000 142,000 144,000 41,500 362,500 35,000 142,000 144,000 41,500 362,500

Strategy 6 - Nutrition and Health Information 218,720 501,420 485,220 473,920 1,679,280 418,720 666,920 897,220 901,920 2,884,780 418,720 673,920 972,220 917,920 2,982,780

P. Surveillance/Surveys 150,000 291,500 309,000 309,000 1,059,500 300,000 449,000 649,000 484,000 1,882,000 300,000 449,000 714,000 484,000 1,947,000

Q. Operational or formative research 5,000 125,000 62,500 - 192,500 5,000 133,000 71,500 3,000 212,500 5,000 140,000 79,500 3,000 227,500

R. M&E 63,720 84,920 113,720 164,920 427,280 113,720 84,920 176,720 414,920 790,280 113,720 84,920 178,720 430,920 808,280


Cost per YearTotal

Cost per YearTotal

Cost per YearTotal


Table 7: Costing Summary Table by Programmatic Area, by Scenario and by Year

2013 2014 2015 2016 2013 2014 2015 2016 2013 2014 2015 2016


Programmatic Area

BNSP 185,283 300,483 292,650 365,950 1,144,367 225,083 384,783 466,250 613,250 1,689,367 226,083 424,333 531,800 714,300 1,896,517

IMAM Services 3,730,077 3,826,230 3,831,501 3,887,628 15,275,435 5,814,107 6,179,452 6,614,550 7,083,150 25,691,258 9,294,580 10,774,799 12,170,051 13,544,400 45,783,831

Micronutrient Treatment and Prevention,

including deworming 167,942 200,572 167,150 172,095 707,758 474,292 539,142 515,585 532,805 2,061,823 599,997 660,847 636,345 662,290 2,559,478

Food-based interventions to vulnerable

populations 586,000 584,000 584,000 584,000 2,338,000 4,621,060 4,621,940 4,624,820 4,627,700 18,495,520 8,983,340 9,224,380 9,684,840 9,752,880 37,645,440

Supporting environment for IYCF 15,367 81,067 25,450 67,200 189,083 55,117 138,117 125,650 122,800 441,683 98,217 203,367 163,050 202,700 667,333

IYCF services 78,766 102,128 143,490 197,002 521,386 101,748 158,822 233,646 293,220 787,436 117,310 228,108 332,656 427,304 1,105,378

System 571,610 814,267 715,883 530,883 2,632,643 711,893 1,069,217 936,333 704,333 3,421,776 846,893 1,336,417 1,198,533 956,533 4,338,376

Coordination 41,300 43,300 29,300 29,300 143,200 41,500 43,500 29,500 29,500 144,000 41,500 43,700 29,500 29,500 144,200

Integration 13,640 22,740 29,440 30,640 96,460 166,865 200,735 236,000 255,455 859,055 427,415 607,615 753,515 896,830 2,685,375

M&E, HMIS and Research 193,403 461,953 414,220 351,720 1,421,297 408,403 632,953 822,220 791,720 2,655,297 411,403 632,953 902,220 791,720 2,738,297

Total 5,583,388 6,436,739 6,233,084 6,216,418 24,469,629 12,620,068 13,968,660 14,604,554 15,053,933 56,247,216 21,046,738 24,136,519 26,402,511 27,978,457 99,564,225


Cost per YearTotal

Cost per YearTotal

Cost per YearTotal


Table 8: Costing Summary Table by Strategy and Programmatic Area, by Scenario and by Year

2013 2014 2015 2016 2013 2014 2015 2016 2013 2014 2015 2016


Results Framework

Strategy 1: LGM 149,640 403,540 231,140 97,190 881,510 205,615 459,940 298,240 162,540 1,126,335 205,740 470,890 310,190 176,640 1,163,460

Strategy 2: HR 671,426 754,283 755,683 919,683 3,101,076 842,210 980,733 1,088,133 1,263,633 4,174,710 1,014,710 1,332,433 1,452,333 1,694,833 5,494,310

Strategy 3: SD - - - - - - - - - - - - - - -

BNSP 89,000 101,850 115,000 131,500 437,350 271,700 311,445 367,060 423,115 1,373,320 542,275 732,375 915,575 1,090,390 3,280,615

IMAM Services 2,114,250 2,138,550 2,152,750 2,158,850 8,564,400 2,889,350 3,066,150 3,319,250 3,552,250 12,827,000 3,880,750 4,586,950 5,289,050 5,950,950 19,707,700

Micronutrient Treatment and Prevention,

including deworming 11,275 14,525 18,150 21,675 65,625 14,485 42,685 50,345 56,415 163,930 41,850 51,350 57,105 63,310 213,615

Food-based interventions to vulnerable

populations 104,000 104,000 104,000 104,000 416,000 1,968,000 1,968,000 1,968,000 1,968,000 7,872,000 2,020,000 2,195,150 2,620,150 2,620,150 9,455,450

IYCF services 41,466 50,478 61,290 71,802 225,036 65,448 89,472 103,346 125,020 383,286 76,010 121,908 152,806 192,554 543,278

Integrated programmes with other sectors 4,100 4,150 4,200 4,200 16,650 12,000 19,050 20,700 22,200 73,950 19,600 33,200 37,250 41,000 131,050

Strategy 4: Finance 3,300 13,300 3,300 3,300 23,200 3,300 13,300 3,300 3,300 23,200 3,300 28,300 3,300 3,300 38,200

Strategy 5: Supply 2,191,361 2,352,843 2,310,551 2,238,498 9,093,252 5,969,390 6,289,665 6,441,160 6,561,740 25,261,955 12,863,934 13,847,743 14,543,731 15,212,610 56,468,018

Strategy 6: Info 203,570 499,220 477,020 465,720 1,645,530 378,570 728,220 945,020 915,720 2,967,530 378,570 736,220 1,021,020 932,720 3,068,530

Total 5,583,388 6,436,739 6,233,084 6,216,418 24,469,629 12,620,068 13,968,660 14,604,554 15,053,933 56,247,216 21,046,738 24,136,519 26,402,511 27,978,457 99,564,225


Cost per YearTotal

Cost per YearTotal

Cost per YearTotal


Annex 1: Participating organisations in the development of the Nutrition PoA

Organisation Workshop 1

Workshop 2

Workshop 3

Ministry of Health

UNICEF

WFP

WHO

Save the Children

Care

SRCS

FSNAU

Merlin

World Vision

Relief International

Ministry of Women’s Development and Family Affairs

Agency for Peace and Development

Horn Alliance Relief and Development

Annex 2: Puntland Activities Matrix (PLAM) The Puntland Activities Matrix is an excel database which is available separately.


Annex 3: Puntland Results Framework Annual Milestones

Plan Target 2013 2014 2015 2016

Building Block 1: Leadership, Governance and Management for Nutrition

Strategy 1: Strengthen the MOH capacity in Leadership and Governance to better implement the core functions of the MOH for the delivery of an effective quality of health and nutrition services

Objective 1 Policies, Strategies, Guidelines and Plans: A policy and strategy framework and planning and budgeting cycle to improve performance of nutrition programmes by end of 2016 Baseline - 2011-2013 Nutrition Strategy in place - 2012-2015 IYCF Strategy and Plan of Action in place - Nutrition not fully integrated in health sector planning processes - There is no nutrition sector wide planning and budgeting system in place - The International Code of Breast Milk Substitutes has not been adopted yet in Puntland, but there are plans for this - Laws currently exist regarding maternity protection but they are not sufficient and they have varied practice with little/no enforcement - National nutrition Emergency Preparedness and Response Plans (EPRP) not fully in place - Nutrition fully integrated in 2013 – 2016 HSSP plans - Costed nutrition plan of action developed as part of HSSP planning and disseminated at national and regional levels - Biannual planning and review process for nutrition established at national and regional level in line with health sector JAR mechanisms - First annual nutrition operational plan and budget developed - Micronutrient Strategy and Action Plans developed and disseminated at national and regional levels - Nutrition sub-sector capacity development plan developed - Nutrition EPRP plans in place and response capacity at national and regional levels established - National level community strategies by MoH adequately consider and program for inclusion of critical nutrition activities (BNSP) - A policy embodying the essence of

- Biannual national planning and review meetings conducted - Second annual nutrition operational plan and budget developed and partnerships for its rollout agreed - Communication and Advocacy strategy for nutrition is developed and implementation started - A Maternity Protection act is drafted (S2&3) - Nutrition EPRP plans reviewed and implemented - Advocacy for BNSP and enactment of

- Nutrition Policy developed and strategy reviewed and updated in line with HSSP - Biannual national planning and review meetings conducted - Third annual nutrition operational plan and budget developed - Nutrition EPRP plans reviewed and implemented

- Biannual national planning and review meetings conducted - Fourth annual nutrition operational plan and budget developed - Nutrition EPRP plans reviewed and implemented - Advocacy for a) BNSP, b)

- By 2016 functional policy, legal, planning and budgeting framework for nutrition in place to create an enabling environment for optimum maternal and child nutrition - Nutrition Communication and Advocacy Strategy developed and in place - By 2016, Nutrition EPRP plans fully established, reviewed and updated on an annual basis and inform emergency response - MoH community strategy adequately considers and includes essential nutrition interventions


the CODE of BMS is developed and endorsed by the Government and disseminated (S2&3) - Advocacy for BNSP and enactment of the CODE as legislation conducted (S2&3)

the CODE as legislation conducted (S2&3)

- Advocacy for a) BNSP, b) enactment of the CODE as legislation, and c) the Maternity Protection act conducted (S2&3)

enactment of the CODE as legislation, and c) the Maternity Protection act conducted (S2&3) - CODE of BMS enacted and disseminated and supportive legislation in place (S2&3)

Indicator 1.1 Number of nutrition related Legal Acts, Policies, Strategies and Plans produced as specified in the PoA

Source MoH Annual Report

Objective 2 Coordination & Partnership: Alignment of all partners and external assistance to this Plan of Action and the HSSP to improve effectiveness of resources for nutrition Baseline - Nutrition coordination mechanism in place at the national level but needs to be enhanced including multi-sectoral coordination - Nutrition coordination mechanism at regional level not in place - Framework for Nutrition Sector coordination and partnership as sub-sector of Health (at national and regional levels) established and functioning - Nutrition coordination structures including thematic sub-working groups functional at national level

- Nutrition coordination structures functional at national (including inter-sectoral coordination) and fully established at regional level

- Nutrition coordination structures functional at national and regional level

- Nutrition coordination structures functional at national and regional level

- By 2016 framework for Nutrition Sector coordination and partnerships established and fully operational

Indicator 1.2a Number of national and regional nutrition coordination structures in place and functional

Source MoH Annual Report

Indicator 1.2b Percentage of partner organisations with regular attendance in coordination meetings (at 90% of the meetings)

Source Minutes of Coordination meetings

Objective 3 L&M Capacity: Enhanced leadership and management for better implementation of the core functions for nutrition of the MOH by the end of 2016 Baseline - MOH Capacity Development Plan for Leadership, Governance and Management Plan is in place - MOH Central level Nutrition Unit is within the PHC Department, with varied levels of capacity for their various functions - MOH Regional Health Office are in place and recently include Regional Nutrition Officers; however they have limited capacity for both management and leadership - Varied and limited systematic supportive supervision, with some agencies conducting supportive supervision on a monthly basis

- Year 1 leadership and management plan rolled out for nutrition senior managers at national and regional level



- By 2016, Nutrition Senior Managers in the MoH (National and Regional) achieve required competencies in planning, budgeting, coordination and management of the nutrition programme in line with health sector L&M programme (ref BB2)

Indicator 1.3 Number of senior nutrition managers trained in line with L&M Programme


Source Nutrition L&M Training Reports

Annual Milestones Plan Target

2013 2014 2015 2016

Building Block 2: Human Resources for Health and Nutrition

Strategy 2: Establish a skilled, well-managed, motivated and equitably distributed workforce for nutrition and health

Objective 1 HR Policies, Planning and Management: Improved human resource development management with harmonized incentives and allowances for effective nutrition programming Baseline HR Policy and Planning - There is no policy, strategy, system or plan for health and nutrition workers/volunteers, causing particular difficulty relating to community-based workers/volunteers where multiple mechanisms are simultaneously emerging to manage this cadre of staff HR Management - Standardised job descriptions for nutrition staff do not exist; - Existing job descriptions for health staff do not fully integrate nutrition responsibilities where applicable - Varied mechanisms for remuneration of community-based health and nutrition workers/volunteers - Health and nutrition staff in government health facilities do not have contracts, only nomination letters - Standard remuneration scales have been established and agreed across the health sector, including for community based health and nutrition workers/volunteers - All HR management tools for nutrition and health staff (including job descriptions) are reviewed, adapted and in place

- All HR management tools for nutrition and health staff are implemented

- Nutrition Association of Puntland is established

- HR management tools, including standard job descriptions for nutrition staff are established and in place; health staff job descriptions include their nutrition responsibilities - Standard remuneration package is applied for all nutrition and health staff, including community-based staff/volunteers based on agreed EPHS standards - Nutrition Association of Puntland is established

Indicator 2.1 Percentage of staff under contract and receiving an annual appraisal at the end of the year

Source HR Records and Reports

Objective 2 HR Production & Capacity: Greater access to qualified providers of nutrition services, particularly at the community level Baseline HR Production - There are no higher education institution that trains nutritionists


- The nutrition curriculum for health training institutions (nursing, midwifery, medical, etc.) is limited and out-of-date HR Capacity - HR capacity assessment for nutrition has not yet been undertaken - Health staff at facility level have limited education and background on nutrition, coupled with the deficiencies in the curriculum - There is very limited capacity of community-based health and nutrition workers/volunteers who undergo inadequate training for their role (few days only); approximately 100 people trained throughout Puntland - In-service training is currently ad-hoc based on needs identified during monitoring as well as roll-out of specific interventions; while a standard in-service training curriculum exists, it is not systematically utilised across all programmes and all partners nor is its use enforced. - HR Capacity Assessment for nutrition undertaken - Higher Education Institutions are identified, assessed and partnerships established - Existing curriculum for nutrition within health training institutes (nursing, midwifery, medical, etc) reviewed - All community based curriculums incorporate BNSP promotion - 50% of health workers in health facilities have basic knowledge and skills to implement at least 5/8 of the BNSP components

- Roll-out of the Capacity Development Strategy (ref BB1) has begun - Capacity strengthening of selected Higher Education Institutions for nutrition training has begun - Curriculum for nutrition within health training institutes (nursing, midwifery, medical, etc) begun to be adapted and standardized - An integrated IYCF curriculum is developed for Health Training Institutions (S3) - Nutrition training programme(s) established within a higher education institution - 60% of health workers in health facilities have basic knowledge and skills to implement at least 5/8 of the BNSP components

- Roll-out of the Capacity Development Strategy (ref BB1) continued - Capacity strengthening of selected Higher Education Institutions for nutrition training continued - Curriculum for nutrition within health training institutes (nursing, midwifery, medical, etc) adaption and standardization complete - The new IYCF curriculum is in place and monitored (S3) - Nutrition training programme(s) within a higher education institution is functional - 70% of health workers in health facilities have basic knowledge and skills to implement at least 5/8 of the BNSP components

- Roll-out of the Capacity Development Strategy (ref BB1) continued - 80% of health workers in health facilities have basic knowledge and skills to implement at least 5/8 of the BNSP components

- Capacity Development Strategy (ref BB1) is rolled-out - Nutrition training programme is established within higher education institutions - 30 students have enrolled in the nutrition training programme with 10 graduated as nutritionists - Standard in-service package developed and in place (S1&2), including an integrated IYCF component (S3) - Community health and nutrition workers/volunteers curriculums adequately include quality BNSP promotion - 80% of health workers in health facilities have basic knowledge and skills to implement at least 5/8 of the BNSP components

Indicator 2.2 Number of new graduates from nutrition training programmes

Source Records from training institutions


2013 2014 2015 2016

Building Block 3: Service Delivery

Strategy 3: Roll out integrated health and nutrition services in all regions

Objective 1 Facility-based Service Delivery: Equitable access to the Basic Nutrition Service Package in all public health facilities in all regions in by December 2016 IMAM Services Baseline


- 43% (30/70) of HCs have fixed IMAM sites; 12 mobile OTP teams (84 mobile sites) cover major towns; 3 SCs; 258 TSFP sites; OTP/TSFP integrated in 26 % (30/114) of OTP sites; OTP services are limited in coastal areas; - All IDP settlements have OTP services - Coverage surveys of services are not systematic; Garowe town coverage is 76% (SFP); Bossaso =75% (OTP & SFP); Galkayo district coverage=42% (SAM) - 60% of HCs have routine IMAM services; - IMAM services are reviewed, rationalised and adjusted as appropriate; - 30% (S1), 50% (S2&3) of OTP/TSFP are integrated; - Additional mobile team in each of 2 coastal districts; - 6 (S2), 8 (S3) additional mobile teams for rural villages covering some pastoral settlements - 2 (S1: Gardo, Burtinle), 3 (S2: plus Eyl), 4 (S3: plus Badhan) additional SC; - 70% (S1&2), 75% (S3) of IMAM services with appropriately trained and qualified staff - 60% of the estimated caseload of children with AM are admitted for treatment (utilization) - 80% of IMAM services meet performance standards - These programmes will achieve a point coverage of 50% (S1&2), 60% (S3) of SAM children for IDP locations and 40% (S1&2), 50% (S3) for other locations

- 70% (S1&2), 75% (S3) of HCs have routine IMAM services; - IMAM services are reviewed and adjusted as appropriate; - 40% (S1), 60% (S2), 65% (S3) of OTP/TSFP are integrated; - Additional mobile team in each of 2 coastal districts; - 6 (S2), 8 (S3) additional mobile teams for rural villages covering some pastoral settlements - 1 (S1: Eyl), 3 (S2: Badhan + 2 more), 4 (S3) additional SC - 80% of IMAM services with appropriately trained and qualified staff - 70% of the estimated caseload of children with AM are admitted for treatment (utilization) - 85% of IMAM services meet performance standards - These programmes will achieve a point coverage of 60% (S1&2), 70% (S3) of SAM children for IDP locations and 50% (S1&2), 60% (S3) for other locations

- 85% (S1&2), 90% (S3) of HCs have routine IMAM services; - IMAM services are reviewed and adjusted as appropriate; - 50% (S1), 70% (S2), 80% (S3) of OTP/TSFP are integrated; - Additional mobile team in each of 2 coastal districts; - 6 (S2), 8 (S3) additional mobile teams for rural villages covering some pastoral settlements - 1 (S1: Badhan), 2 (S2), 4 (S3) additional SC; - 90% of IMAM services with appropriately trained and qualified staff - 80% of the estimated caseload of children with AM are admitted for treatment (utilization) - 90% of IMAM services meet performance standards - These programmes will achieve a point coverage of 70% (S1&2), 80% (S3) of SAM children for IDP locations and 60% (S1&2), 70% (S3) for other locations

- 90% (S1), 95% (S2), 100% (S3) of HCs have OTP services; - IMAM services are reviewed and adjusted as appropriate; - 60% (S1), 80% (S2), 95% (S3) of OTP/TSFP are integrated; - Additional mobile team in each of 2 coastal districts; - 6 (S2), 8 (S3) additional mobile teams for rural villages covering some pastoral settlements - 2 (S2), 4 (S3) additional SC; - 100% of IMAM services with appropriately trained and qualified staff - 80% (S1&2), 90% (S3) of the estimated caseload of children with AM are admitted for treatment (utilization) - 95% of IMAM services meet performance standards - These programmes will achieve a point coverage of 80% (S1&2), 85% (S3) of SAM children for IDP locations and 70% (S1&2), 75% (S3) for other locations

- 90% (S1), 95% (S2), 100% (S3) of functioning HCs have OTP services - IMAM services are systematically reviewed and adjusted according to needs - 60% (S1), 80% (S2), 95% (S3) of OTP/TSFP are integrated; - OTPs are maintained in all IDP settlements (25 mobile teams); - 80% (~112/140) of coastal villages have OTP services through 8 additional mobile teams; - 70% (S2), 100% (S3) of rural villages including some pastoral settlements have OTP services through 24 (S2), 32 (S3) additional mobile teams; - 7 (S1), 10 (S2), 15 (S3) functioning SCs within RHCs and Hospitals; - 100% of IMAM services with appropriately trained and qualified staff (HR) - 80% (S1&2), 90% (S3) of the estimated caseload of children with AM are admitted for treatment (utilization) - 95% of IMAM services meet SPHERE performance standards - These programmes will achieve a point coverage of 80% (S1&2), 85% (S3) of SAM children for IDP locations and 70% (S1&2), 75% (S3) for other locations

Food-based Interventions Baseline - MCHN - 79% (55/70) of HCs provide supplementary feeding through the MCHN programme to pregnant and lactating women (PLWs) and children under 2 years old (U2s); - Quality of implementation is varied


- 85% of HCs provide supplementary feeding to all U2s and PLWs attending ANC/PNC (S2&3) - In all HCs implementing the MCHN programme, women delivering at the facility receive an incentive ration (S3)




- 100% of HCs provide supplementary feeding to all U2s and PLWs attending ANC/PNC (S2&3), as well as an incentive ration to women delivering at the health facility (S3)

Baseline – Institutional Feeding for HIV & TB Patients - Relief household food assistance is provided to all HIV and TB patients on a treatment course in 8 out of 10 TB centres and in 3 out of 4 ART centres; - Supplementary feeding is provided to all malnourished HIV and TB patients on a treatment course in the same centres; - 'Food by Prescription' is just beginning - National guidance on nutritional care and treatment of PLHIV and TB patients are developed and endorsed by health authorities (S2&3) - All functioning (9) HIV/TB clinics have anthropometric equipment and materials and provide supplementary feeding for malnourished patients (S2&3) and a household food ration to all patients (S3)

- All health staff in charge of nutritional care and treatment of PLHIV and TB are trained on NAEC and prescription of supplementary feeding to PLHIV and TB (S2&3) - National guidance on nutritional care and treatment of PLHIV and TB and related materials are available at clinic level (S2&3) - All functioning (12) HIV/TB clinics provide a full package of nutrition services to clients including NAEC and supplementary feeding for malnourished patients (S2&3) and a household food ration to all patients (S3)

- All functioning (14) ART and TB centres deliver nutrition services including NAEC, supplementary feeding for the malnourished patient only (S2&3), and a household food ration to all patients (S3)



Management and Treatment of Micronutrient Deficiencies and Malnutrition Baseline Treatment of Micronutrient Deficiencies - Generally, treatment of MND is not consistent across facilities - Anaemia is treated in all HCs for adults, kids aren't treated adequately (syrups missing); - Vitamin A is supplied to all HCs but not always implemented; - Iodine Deficiency is not treated, and there is indication of Iodine Excess in populations - this is being further investigated Treatment of Diarrhoea with Zinc/ORS - Zinc for treatment of diarrhoea is available in all HCs but is systematically implemented in approximately 60% of HCs; there are questions of supply and implementation issues and the quality of the service is varied


- 50% (S1), 60% (S2), 70% (S3) of HCs treat Vitamin A Deficiency - 50% (S1), 60% (S2), 70% (S3) of HCs treat diarrhoea with Zinc/ORS as well as 20% of IMAM services (outside HCs) - Treatment of anaemia is maintained (S1), is scaled up to 10% (S2), 25% (S3) of HCs treating anaemia in young children - MND protocols are available in all of these HCs and these services are adequately monitored and supervised to ensure quality

- 60% (S1), 70% (S2), 80% (S3) of HCs treat Vitamin A Deficiency - 60% (S1), 70% (S2), 80% (S3) of HCs treat diarrhoea with Zinc/ORS as well as 30% (S1), 35% (S2), 40% (S3) of IMAM services (outside HCs) - Treatment of anaemia is maintained (S1), is scaled up to 25% (S2), 50% (S3) of HCs treating anaemia in young children - MND protocols are available in all of these HCs and these services are adequately monitored and supervised to ensure quality




Baseline – Micronutrient Supplementation Vitamin A - Vitamin A supplementation is carried out through IMAM programmes, Routine Immunization at all HCs and outreach for U5s and postpartum women, CHDs and NIDs for U5s; - This is systematically taking place but reporting, monitoring and supervision are not systematic so the quality could be variable Deworming - Deworming of U5s is done through HCs, IMAM (mainly OTP, some TSFP), mobile and outreach services; this is systematically provided but with varied quality - Currently, 70 schools in Nugal region have a school deworming programme; however, there are plans to change schools and only integrate in primary schools with School Feeding programme (106/500). Additionally, ad-hoc deworming campaigns in schools are planned. - An integrated school health programme is planned in Galkayo, Garowe and Bossaso, which includes deworming (~30 schools) Iron Folate & Multiple Micronutrient Supplements (MMNs) for PLWs - Multiple micronutrient supplements are provided to PLWs through HCs and TSFP and, during emergencies, through outreach; - It is not systematically given due to supply and implementation issues - The quality of the service varies Home Fortification Products (Micronutrient Powders – MNPs) - This is not yet underway; there are plans for a pilot in U2s after a feasibility study is[MD1] conducted - 70% of HCs provide Vitamin A supplementation and deworming for U5s and postpartum women; - 70% of IMAM and outreach services provide Vitamin A supplementation and deworming; - (S1) 100% of HCs/mobile services and TSFP sites provide Iron Folate to PLWs - 50% (S2), 70% (S3) of HCs/mobile

- 80% of HCs provide Vitamin A supplementation and deworming for U5s and postpartum women; - 70% (S1&2), 80% (S3) of IMAM and outreach services provide Vitamin A supplementation; - (S1) 100% of HCs/mobile services and TSFP sites provide Iron Folate to PLWs - 60% (S2), 80% (S3) of HCs/mobile

- 90% of HCs provide Vitamin A supplementation and deworming for U5s and postpartum women; - 70% (S1), 80% (S2), 90% (S3) of IMAM and outreach services provide Vitamin A supplementation; - (S1) 100% of HCs/mobile services and TSFP sites provide Iron Folate to PLWs - 70% (S2), 90% (S3) of HCs/mobile

- 100% of HCs provide Vitamin A supplementation and deworming for U5s and postpartum women; - 80% (S1), 90% (S2), 100% (S3) of IMAM and outreach services provide Vitamin A supplementation; - (S1) 100% of HCs/mobile services and TSFP sites provide Iron Folate to PLWs - 80% (S2), 100% (S3) of HCs/mobile

- 100% of HCs provide Vitamin A supplementation and deworming for U5s and postpartum women; - 80% (S1), 90% (S2), 100% (S3) of outreach services and mobile IMAM services provide Vitamin A for U5s; - (S1) 100% of HCs/mobile services and TSFP sites provide Iron Folate to PLWs - 80% (S2), 100% (S3) of HCs/mobile


services and 100% (S2&3) of TSFP sites provide MMNS to PLWs - All HCs are provided with supplies, routinely report and are adequately monitored - Initiate a pilot project for home fortification of children U2 with close monitoring, supervision and documentation of lessons learned (S2&3) - 100% of school feeding programmes provide deworming for children (S2) - 40% of primary schools give bi-annual deworming to students and where possible integrate into school health programs (S3)

services and 100% (S2&3) of TSFP sites provide MMNS to PLWs - All HCs are provided with supplies, routinely report and are adequately monitored - At least 5% of children U2 in select areas receive home fortification products (S2&3) - 100% of school feeding programmes provide deworming for children (S2) - 50% of primary schools give bi-annual deworming to students and where possible integrate into school health programs (S3)

services and 100% (S2&3) of TSFP sites provide MMNS to PLWs - All HCs are provided with supplies, routinely report and are adequately monitored - At least 10% (S2), 20% (S3) of children U2 in select areas receive home fortification products - 100% of school feeding programmes provide deworming for children (S2) - 65% of primary schools give bi-annual deworming to students and where possible integrate into school health programs (S3)

services and 100% (S2&3) of TSFP sites provide MMNS to PLWs - All HCs are provided with supplies, routinely report and are adequately monitored - At least 20% (S2), 40% (S3) of children U2 in select areas receive home fortification products - 100% of school feeding programmes provide deworming for children (S2) - 80% of primary schools give bi-annual deworming to students and where possible integrate into school health programs (S3)

services and 100% (S2&3) of TSFP sites provide MMNS to PLWs - All HCs have protocols in place, as well as systematic monitoring, supervision and reporting - At least 20% (S2), 40% (S3) of children U2 in select areas, agreed through coordination mechanisms, receive home fortification products - 100% of school feeding programmes provide deworming for children (S2) - 80% of primary schools give bi-annual deworming to students and where possible integrate into school health programs (S3)

IYCF Services Baseline – Facility Based IYCF Services Counselling - ~20% of HCs provide IYCF counselling services - There is little/no reporting on facility-based IYCF counselling; - 17 Trainers of Trainers (TOTs) have been trained; - ~15% (100/650) of OTP, TSFP and HC staff are trained IYCF counsellors Mother Support Groups - HCs are not conducting Mother Support Groups - 40% of HCs (S2), HCs, RHCs and Hospitals (S3) systematically provide IYCF counselling services during ANC/PNC/sick child visits and IMAM programmes; - 15% of HCs (S2), 25% of HCs, RHCs and Hospitals (S3) systematically conduct Mother Support Groups - Systematic monitoring, supervision and reporting of these services and activities - 50 (S2), 75 (S3) staff are trained on

- 55% of HCs (S2), 65% of HCs, RHCs and Hospitals (S3) systematically provide IYCF counselling services during ANC/PNC/sick child visits and IMAM programmes; - 20% of HCs (S2), 35% of HCs, RHCs and Hospitals (S3) systematically conduct Mother Support Groups - Systematic monitoring, supervision and reporting of these services and activities - 50 (S2), 75 (S3) staff are trained on

- 70% of HCs (S2), 85% of HCs, RHCs and Hospitals (S3) systematically provide IYCF counselling services during ANC/PNC/sick child visits and IMAM programmes - 25% of HCs (S2), 45% of HCs, RHCs and Hospitals (S3) systematically conduct Mother Support Groups - Systematic monitoring, supervision and reporting of these services and activities - 50 (S2), 75 (S3) staff are trained on

- 85% of HCs (S2), 100% of HCs, RHCs and Hospitals (S3) systematically provide IYCF counselling services during ANC/PNC/sick child visits and IMAM programmes - 30% of HCs (S2), 55% of HCs, RHCs and Hospitals (S3) systematically conduct Mother Support Groups - Systematic monitoring, supervision and reporting of these services and activities - 50 (S2), 75 (S3) staff are trained on

- 85% of HCs (S2), 100% of HCs, RHCs and Hospitals (S3) systematically provide IYCF counselling services during ANC/PNC/sick child visits and IMAM programmes - 30% of HCs (S2), 55% of HCs, RHCs and Hospitals (S3) systematically conduct IYCF Mother Support Groups - Systematic monitoring, supervision and reporting of these services and activities


IYCF counselling and Mother Support Groups from Mobile OTPs, TSFPs and HCs (S2) and RHCs and Hospitals (S3)


IYCF counselling and Mother Support Groups from Mobile OTPs, TSFPs and HCs (S2) and RHCs and Hospitals (S3) - Implement and monitor the new curriculum in Health Training Institutions (S3)


- Referral HC and Hospitals provide IYCF counselling services (S3) - At least 45% (S2), 50% (S3) of OTP, TSFP and HC staff (S2) and RHCs and Hospitals (S3), are trained as IYCF counsellors and on how to conduct Mother Support Groups

BNSP Service Promotion Baseline – Facility Based BNSP Service Promotion - All HCs provide promotion of IYCF during ANC/PNC/sick child visits/EPI but monitoring and supervision is limited; - HFs have health talks (weekly); posters and IEC materials available in all HCs - All partners have been trained on BNSP services but not on specific BNSP promotion - 50 (S2), 75 (S3) people trained on IYCF and BNSP promotion activities during the IYCF counselling training - 40% of HCs systematically conduct IYCF and BNSP promotion activities (S2&3) - 60% of partners implement NHHP at HCs or nutrition sites (S2&3) - Systematic monitoring, supervision and reporting of these activities (S2&3)

- 50 (S2), 75 (S3) people trained on IYCF and BNSP promotion activities during the IYCF counselling training - 65% of HCs systematically conduct IYCF and BNSP promotion activities (S2&3) - 80% of partners implement NHHP at HCs or nutrition sites (S2&3) - Impact of NHHP program is evaluated and results used to increase quality (S3) - Systematic monitoring, supervision and reporting of these activities (S2&3)[MD2]

- 50 (S2), 75 (S3) people trained on IYCF and BNSP promotion activities during the IYCF counselling training - 85% of HCs systematically conduct IYCF and BNSP promotion activities (S2&3) - 90% of partners implement NHHP at HCs or nutrition sites (S2&3) - Impact of NHHP program is evaluated and results used to increase quality (S2) - Systematic monitoring, supervision and reporting of these activities (S2&3)

- 50 (S2), 75 (S3) people trained on IYCF and BNSP promotion activities during the IYCF counselling training - 100% of HCs systematically conduct IYCF and BNSP promotion activities (S2&3) - 100% of partners implement NHHP at HCs or nutrition sites (S2&3) - Systematic monitoring, supervision and reporting of these activities (S2&3)

- 45% (S2), 50% (S3) of OTP, TSFP and HC staff are trained on IYCF and how to conduct IYCF and BNSP promotion activities - 100% of HCs systematically conduct IYCF and BNSP promotion activities (S2&3) - 100% of partners implement quality NHHP at HCs or nutrition sites (S2&3) - Systematic monitoring, supervision and reporting of these activities (S2&3)

Indicator 3.1a Percent of EPHS facilities implementing BNSP services

Source EPHS Progress/Interim Reports

Indicator 3.1b Percentage of PLWs within the health facility catchment population that receive IYCF counselling services

Source Monthly IYCF reports, KAP and coverage surveys and nutrition assessments


2013 2014 2015 2016

Building Block 3: Service Delivery

Strategy 3:

Objective 2 Community level Service Delivery: Increase access to basic nutrition services to rural areas through community based initiatives

IMAM Services Baseline


Something should be added on the status of community based IMAM (not the mobile part but the part that stays in the community) This part should be reviewed by the PL Team - Community involvement for IMAM services is limited by lack of understanding of community based services, existing tools and human resources - Current outreach and mobile services are being considered as community based interventions - There is varied means of reporting on these activities, causing a lack of understanding on which community components are in place and their quality - 30% of HCs with IMAM services have at least 5 (S1), 15 (S2), 20 (S3) trained CBHWs in their catchment area that conduct and report on the identification and referral of malnutrition, defaulter tracing and follow-up of beneficiaries - 50% of communities with IMAM services (mobile or community-based) have at least 2 trained CBHWs that conduct and report on the identification and referral of malnutrition, defaulter tracing and follow-up of beneficiaries - 80% of referrals from CBHWs benefit from IMAM services

- 40% of HCs with IMAM services have at least 5 (S1), 15 (S2), 20 (S3) trained CBHWs in their catchment area that conduct and report on the identification and referral of malnutrition, defaulter tracing and follow-up of beneficiaries - 60% of communities with IMAM services (mobile or community-based) have at least 2 trained CBHWs that conduct and report on the identification and referral of malnutrition, defaulter tracing and follow-up of beneficiaries - 80% of referrals from CBHWs benefit from IMAM services




Food-based Interventions Baseline – BSFP – in critical situations - The decision to implement BSFP is based on the seasonal analysis of needs - In Margaga and Bossaso IDPs, BSFP is provided seasonally; - In other locations, BSFP is only when there is high need - BSFP is provided to children under 2 and pregnant and lactating women in these locations In all areas affected by >20% (S1), >15% (S2), 10-15% (S3) GAM prevalence and/or with medium to high risk of deterioration

In all areas affected by >20% (S1), >15% (S2), 10-15% (S3) GAM prevalence and/or with medium to high risk of deterioration



BSFP is provided to U2s (S1) and PLWs (S2&3) in all areas affected by >20% (S1), >15% (S2), 10-15% (S3) GAM prevalence and/or with medium to high risk of deterioration

Management and Treatment of Micronutrient Deficiencies and Malnutrition

Baseline – Treatment of Micronutrient Deficiencies This part should be reviewed by the SL Team - Treatment of anaemia, vitamin A deficiency and diarrhoea are currently managed at the health facility level, not at the community level - 100% of trained CBHWs treat mild-moderate diarrhoea as well as identify and refer anaemia, vitamin A deficiency and severe diarrhoea cases - 80% of CBHWs report on these

- 100% of trained CBHWs treat mild-moderate diarrhoea as well as identify and refer anaemia, vitamin A deficiency and severe diarrhoea cases - 80% of CBHWs report on these





services and referrals services and referrals services and referrals services and referrals services and referrals

Baseline – Vitamin A, Deworming, Multiple Micronutrient Tablets and Home Fortification Products Vitamin A - Vitamin A supplementation is carried out through outreach for U5s and postpartum women, CHDs and NIDs for U5s Deworming - Deworming of U5s is done through CHDs for U5s; it is systematically provided but with varied quality Multiple Micronutrient Supplements (MMNs) for PLWs - There is no programme currently for multiple micronutrient supplementation of PLWs at the community level Home Fortification Products (Micronutrient Powders – MNPs) - There is currently no programme in place that provides home fortification products to children at the community level - CHDs and NIDs achieve 80% coverage of U5s with Vitamin A supplementation and deworming - Initiate a pilot project for home fortification of children U2 with close monitoring, supervision and documentation of lessons learned (S2&3)

- CHDs and NIDs achieve 80% (S1), 85% (S2), 90% (S3) coverage of U5s with Vitamin A supplementation and deworming - At least 5% of children U2 in select areas receive home fortification products (S2&3)

- CHDs and NIDs achieve 85% (S1), 90% (S2), 95% (S3) coverage of U5s with Vitamin A supplementation and deworming - At least 10% (S2), 20% (S3) of children U2 in select areas receive home fortification products

- CHDs and NIDs achieve 90% (S1), 95% (S2), 100% (S3) coverage of U5s with Vitamin A supplementation and deworming - At least 20% (S2), 40% (S3) of children U2 in select areas receive home fortification products

- CHDs and NIDs achieve 90% (S1), 95% (S2), 100% (S3) coverage of U5s for Vitamin A supplementation and deworming - At least 20% (S2), 40% (S3) of children U2 in select areas, agreed through coordination mechanisms, receive home fortification product - Community-based Micronutrient supplementation protocols are in place with systematic monitoring and supervision of these services

IYCF Services Baseline – Community Based IYCF Services Individual Counselling - 3 out of 5 IDP populations (60/84 IDP camps) have counselling services with 82 trained counsellors; - In other locations, there is limited community-based counselling services (<1%, 5/700 villages) - Varied quality of counselling services - Limited reporting on community-based IYCF counselling services Mother-to-mother Support Groups - 95 Mother-to-mother Support Groups are active in Garowe, Bossaso and Galkayo IDP locations


- 10 (S1), 20 (S2), 30 (S3) communities establish CB IYCF programmes including counselling and MSGs by community volunteers - 1 additional IDP population establishes CB IYCF services including counselling and MSGs - Programme monitoring, reporting and supervision is established - Within locations with counselling services and MSGs, at least 60% of the PLWs and mothers of U2s are reached or participate

- 10 (S1), 20 (S2), 40 (S3) communities establish CB IYCF programmes including counselling and MSGs by community volunteers - 1 additional IDP population establishes CB IYCF services including counselling and MSGs - Programme monitoring, reporting and supervision is established - Within locations with counselling services and MSGs, at least 60% of the PLWs and mothers of U2s are reached or participate

- 10 (S1), 20 (S2), 40 (S3) communities establish CB IYCF programmes including counselling and MSGs by community volunteers - All IDP settlements maintain their CB IYCF services including counselling and MSGs - Programmes systematically monitor, report and supervise these activities - Within locations with counselling services and MSGs, at least 60% of the PLWs and mothers of U2s are reached or participate

- 10 (S1), 20 (S2), 40 (S3) communities establish CB IYCF programmes including counselling and MSGs by community volunteers - All IDP settlements maintain their CB IYCF services including counselling and MSGs - Programmes systematically monitor, report and supervise these activities - Within locations with counselling services and MSGs, at least 60% of the PLWs and mothers of U2s are reached or participate

- 6% (S1: 40/700), 12% (S2: 80/700), 20% (S3: 150/700) of communities have CB counselling services and Mother-to-Mother Support Groups, including some coastal villages - 100% of IDP settlements have CB counselling services and MSGs - All programmes have systematic monitoring, reporting and supervision - Within locations with counselling services and MSGs, at least 60% of the PLWs and mothers of U2s are reached or participate

BNSP Service Promotion Baseline – Community Based BNSP Service Promotion - 111 community volunteer carry out IYCF promotion activities within ~3% of communities (22/700) and 43 IDP camps (Bossaso, Garowe, Galkayo) some during IMAM services; - Community level sensitization is carried out through meetings, posters, and leaflet distribution; - 12 (S1), 24 (S2), 33 (S3) communities have established CB IYCF programmes including IYCF and BNSP promotion by community volunteers - 1 additional IDP population has established CB IYCF services including IYCF and BNSP promotion - Programmes systematically monitor, report and supervise these activities

- 12 (S1), 24 (S2), 40 (S3) communities have established CB IYCF programmes including IYCF and BNSP promotion by community volunteers - 1 additional IDP population has established CB IYCF services including IYCF and BNSP promotion - Programmes systematically monitor, report and supervise these activities - Quality of BNSP promotion at community level is evaluated and the information is used to improve quality (S2&3)

- 12 (S1), 25 (S2), 40 (S3) communities have established CB IYCF programmes including IYCF and BNSP promotion by community volunteers - All IDP settlements maintain their CB IYCF services including IYCF and BNSP promotion - Programmes systematically monitor, report and supervise these activities

- 12 (S1), 25 (S2), 40 (S3) communities have established CB IYCF programmes including IYCF and BNSP promotion by community volunteers - All IDP settlements maintain their CB IYCF services including IYCF and BNSP promotion - Programmes systematically monitor, report and supervise these activities - Quality of BNSP promotion at community level is re-evaluated and that information is used to improve quality (S3)

- 10% (S1: 70/700), 17% (S2: 120/700), 25% (S3: 175/700) of communities have CB IYCF and BNSP promotion activities, including some coastal villages (S1,2&3) and rural villages (S2&3) and pastoral groups (S3); these are expanded to secondary school in these communities (S3) - 100% of IDP settlements have CB IYCF and BNSP promotion activities; - All programmes have systematic monitoring, reporting and supervision

Baseline – Community Mobilisation/Ownership of BNSP Services - Not really going on yet, IYCF programming still young in Puntland; - Some CHCs have been established and could include IYCF activities; - In IDP camps, ownership is stronger and IYCF activities are continuing after programme completion - 40% of intervention communities have structured screening and referral services for IMAM - Ways to increase ownership of BNSP at community level are investigated (S2&3)

- A communications and advocacy program is implemented in 2 (S2), 4 (S3) districts to increase ownership of BNSP at community level

- BNSP communication and advocacy programme scaled-up to a total of 6 (S2), 8 (S3) districts

- BNSP communication and advocacy programme scaled-up to a total of 10 (S2), 12 (S3) districts - Evaluate effectiveness of

- A communication/advocacy program to increase community ownership of BNSP is implemented and evaluated in 25% (S2: 10/40),


- 45% (S2), 50% (S3) of communities with nutrition services have structured screening and referral services for BNSP - Systematic monitoring, supervision and reporting of these activities (S2&3)



communication and advocacy for BNSP (S2&3) - 60% (S2), 80% (S3) of communities with nutrition services have structured screening and referral services for BNSP - Systematic monitoring, supervision and reporting of these activities (S2&3)

30% (S3: 12/40) of districts - 60% (S2), 80% (S3) of communities with nutrition services have structured screening and referral services for BNSP - Systematic monitoring, supervision and reporting of these activities (S2&3)

Baseline – Communication for Development/Behaviour Change Communication - Limited in scope - Limited analysis of ideal channels to use for targeting specific groups - Materials and a strategy are developed for increasing ownership of BNSP amongst health workers (S2&3) - IPC, radio and print are used to diffuse messages regarding optimal nutrition (S2&3) - A communication channel analysis defines optimum channels for various target groups for nutrition (S3)

- 10% (S2), 20% (S3) of Health workers demonstrate increased understanding of critical nutrition interventions and thereafter provide these services accordingly - The effectiveness of messaging is evaluated (S2&3) - Communication programs are re-oriented based on outcomes of communication channel analysis (S3)

- 15% (S2), 30% (S3) of Health workers demonstrate increased understanding of critical nutrition interventions and thereafter provide these services accordingly - Health workers understanding and provision of nutrition services is assessed and results are used to adapt communications project (S3) - At least 1 (S2), 2 (S3) new communication programme is developed

- 20% (S2), 40% (S3) of Health workers demonstrate increased understanding of critical nutrition interventions and thereafter provide these services accordingly - Health workers understanding and provision of nutrition services is assessed and results are used to adapt communications project (S2)

- 20% (S2), 40% (S3) of Health workers demonstrate increased understanding of critical nutrition interventions and thereafter provide these services accordingly - The effectiveness of communication channels are evaluated for the uptake of messaging by communities and at least 1 (S2), 2 (S3) communication project(s) started to promote optimal BNSP behaviours

Indicator 3.2a Number of communities with community based health workers implementing nutrition activities

Source Community based strategy progress and final reports

Indicator 3.2b Percent of women with appropriate practice of early initiation of breastfeeding

Source KAP Survey


2013 2014 2015 2016

Building Block 4: Financing

Strategy 4: Develop a health and nutrition financing system that relies more on national financing and local resources, aligns funding to Puntland priorities, and is based on sound financial management

Objective 1 Financing: Increase the proportion of the national budget spent on nutrition to 2% by the end of the Plan, while the MOH knows and publishes sources and amounts of international and in-county expenditures on nutrition projects/activities in Puntland Baseline - No systematic advocacy for nutrition financing - No monitoring of government budgets or the allocations for nutrition


- National budget allocation for nutrition is less than 1%; the nutrition allocation within the national health budget is unknown - Nutrition programme financing is determined by individual organisational priorities and not necessarily aligned with national priorities - Nutrition financing begin to support and align with the HSSP and the Nutrition Plan of Action

- Nutrition financing support and align with the HSSP and the Nutrition Plan of Action - Potential local resources for nutrition are identified - Financing advocacy plan developed (BB1) - Advocacy tools developed

- Nutrition financing support and align with the HSSP and the Nutrition Plan of Action - Advocacy for nutrition financing continued - Government budget analysis carried out (S2&3)

- Nutrition financing support and align with the HSSP and the Nutrition Plan of Action - Advocacy for nutrition financing continued - Government budget analysis carried out (S2&3)

- Planning, advocacy (S1,2&3) and monitoring (S2&3) of resources for effective nutrition programming is in place - Nutrition financing support and align with the HSSP and the Nutrition Plan of Action

Indicator 4.1 Proportion of national budget allocated for nutrition

Source MoH Annual Report; National Budget


2013 2014 2015 2016

Building Block 5: Supply

Strategy 5: Protect the population from harmful medicines and products and improve access to quality essential health and nutrition products

Objective 1: MOH has the capacity to manage nutrition supplies in the public sector, including quality control and safety measure for nutrition products Baseline - There is no drug and essential nutritional products registration or licensing system - There is some small scale quality control mechanisms in place (mini-labs) for spot checks on products - Nutrition products and supplies are provided mainly through a push system, largely supported by international organizations - Government involvement in supply chain management for nutrition is limited to planning and distribution at central level - There is little involvement of the regional health offices in planning and management of nutrition supplies - Stock outs for essential nutrition supplies for BNSP are 30% of total supply months - Nutrition supplies are not distributed on a regular basis or on a planned schedule - A central MOH warehouse has been established in 2013 - Maintain existing supply provision for ongoing nutrition programmes - Essential drugs and nutrition products list updated - Supply chain analysis conducted

- Maintain existing supply provision for ongoing nutrition programmes - Drug and essential nutrition products verification system at the pharmacy level in place - Capacity strengthening plan for supply chain management within MOH and partners developed (BB2)

- Drug and essential nutrition products registration and enforcement system in place - Capacity strengthening plan for supply chain management within MOH and partners operationalised (BB2)

- Drug registration and enforcement system in place - Capacity strengthening plan for supply chain management within MOH and partners continued to be operationalised (BB2)

- Essential drugs’ list is updated to include all critical nutrition products and supplies - The MOH adequately plans, procures, stores and distributes nutrition products and supplies according to actual needs (pull system) - Quality control measures are in place for key nutrition products and supplies, including registration and certification


- Stock outs for essential nutrition supplies for BNSP are less than 20% of total supply months





Indicator 5.1 Percentage of HFs with stock-outs of key nutrition products (RUTF, RUSF, amoxicillin, MMNs, MNPs) less than 10% of total supply months in all of the regions

Source Annual facility survey, HMIS and monitoring reports


2013 2014 2015 2016

Building Block 6: Health and Nutrition Information and Research

Strategy 6: Improve decision making through collecting and analysing comprehensive and accurate information on key health and nutrition metrics

Objective 1 M&E: Improve the scope, quality and utilization of the existing HMIS as well as other M&E systems for effective nutrition programming Baseline - Monitoring systems and tools in place, but not managed by and within MoH or regional nutrition offices - Reporting rate (two months post-implementation) at average of 90% for 2012 and 85% for 2013 for IMAM, limited reporting for other BNSP interventions - 45% of nutrition programmes with at least one follow-up on programme reporting and performance issues, limited joint follow-up including MoH and partners - Minimal/varied utilization of gaps identified in programme capacity and performance - HMIS is in place and functioning with several nutrition indicators, although these are not well incorporated and the quality is varied; quarterly data verification is carried out - Maintain existing monitoring systems and tools for ongoing nutrition programmes and introduction to MoH - Regular (S1), strategic (S2&3) monitoring and evaluation of nutrition programs, including monthly analysis and regular supportive supervision to address gaps - Annual coverage surveys for one region

- Review and update existing monitoring systems and tools for ongoing nutrition programmes - Capacity strengthening plan for programme data management within MOH and partners developed (BB2) - Maintain regular monitoring and evaluation of BNSP programs, including monthly analysis (of BNSP and HMIS reports) and regular supportive supervision to address gaps - Annual coverage surveys for 2 (S1&2), 3 (S3) regions

- Introduce existing monitoring systems and tools for ongoing nutrition programmes within MoH (BB1) - Capacity strengthening plan for programme data management within MOH and partners operationalized (BB2) - Strategic evaluation of nutrition programs, including monthly analysis and supportive supervision to address gaps - Annual coverage surveys for 3 (S1&2), 5 (S3) regions

- Maintain existing monitoring systems and tools for ongoing nutrition programmes within MoH (BB1) - Capacity strengthening plan for programme data management within MOH and partners continue to be operationalized (BB2) - Strategic evaluation of nutrition programs, including monthly analysis and supportive supervision to address gaps - Annual coverage surveys for 4 (S1&2), 7 (S3) regions

- Monitoring and evaluation systems and tools coordinated and managed by MoH - The MOH regularly analyses programme data, including identification of programme gaps and strategic supportive supervision for 100% of nutrition services - Annual coverage surveys for at least 4 (S1&2), 7 (S3) regions are conducted

Indicator 6.1a Number of health facilities and nutrition services providing timely, complete and accurate nutrition reports

Source Nutrition database, HMIS reports and Annual facility survey

Indicator 6.1b Annual IMAM coverage surveys are conducted systematically for at least 4 regions

Source Coverage Survey Results

Objective 2 Research, Surveys & Surveillance: Establish and implement a survey/surveillance and operational research plan for nutrition by 2016


Baseline - Bi-annual national nutrition and food security surveys conducted by livelihood zone, IDP area, and urban settings - Other operational and formative research is carried out on an ad-hoc basis - Nutrition surveys and surveillance conducted as needed (S1), regularly (S2&3) and inform programmes - Priorities for operational and formative research identified and plan developed (S2&3)

- Nutrition surveys and surveillance conducted for better understanding of situation and trends - Priorities for operational and formative research identified and plan developed (S1) - Operational and formative research plan operationalized (S2&3) - Population based IYCF KAP study conducted (S2&3) - Iodine situation in country further investigated (S2) - Compliance of MMNs in PLWs assessed (S3) - Conduct a population based worm prevalence study (S3)

- Nutrition surveys and surveillance conducted for better understanding of situation and trends - Operational and formative research conducted as needed (S1) - Operational and formative research plan continues to be operationalized and findings inform programmes (S2&3) - Population based Micronutrient deficiency survey conducted (S2&3) - Compliance of MMNs in PLWs assessed (S2)

- Nutrition surveys and surveillance conducted for better understanding of situation and trends - Operational and formative research conducted as needed (S1) - Operational and formative research plan continues to be operationalized and findings inform programmes (S2&3)

- Nutrition surveys and surveillance conducted as needed (S1), on a regular basis (S2&3) to inform programmes - Operational and formative research carried out as needed (S1), as planned (S2&3) to inform improved nutrition programming - The general IYCF situation is assessed at least once (S2&3) - The micronutrient status of the population is assessed at least once (S2&3) - Compliance for MMNs is assessed and results used to improve program quality (S2&3) - The iodine situation is further understood (S2&3) - Prevalence of worms in select populations is understood (S3)

Indicator 6.2 Availability of a long term research and survey plan

Source MoH Annual Report; Research and Survey Plan documents and reports