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NEWSLETTER

Back to the Triple-A Approach By Bjorn Ljungqvist

The 1990 UNICEF Nutrition Strategy consists of two equally important components: the Conceptual Framework of Causality and the Triple-A approach. The Conceptual Framework is the basis for a multisectoral, multi-stakeholder approach to nutrition, with food, health and care being components that are all necessary, though not one by itself sufficient. However, this part is well established and understood. The second part, the Triple-A approach, seems to have been neglected, but is now coming back as a critical component of the nutrition scaling-up process.

African Regional Nutrition Strategy

Assessment - Analysis - Action

Africa’s Nutrition Security Partnership

Monitoring Implementation and Demonstrating Results Workshop

A Framework of Multisectoral Nutrition Systems

While the conceptual framework guides the discernment of which

information needs monitoring, the Triple-A approach (of

Assessment, Analysis and Action in a consecutive, iterative and

continual cycle) guides how this information should be used. The

cycle may start with a household-level assessment, with the

mother gauging the growth of her child, or with an assessment at

the community, district or national level of the nutrition situation

of the population. The assessment depends on the awareness of

the problem and the commitment to act. It is thus partly also

dependent on the information available and the systems that

allow this information to be understood and used. After an initial

assessment, the causative factors and determinants need to be

analysed. The analysis is improved when there are inputs from

people who are close to the situation and understand the context

well, i.e., people at the community level as well as those who are

experienced and trained to do such analyses. Actions are taken

based on the assessments and analyses. However, contexts change

and the actions themselves may lead to new situations requiring

the need to re-assess, reanalyse and re-think the actions. Strong

motivation, supported by advocacy and social mobilization, is

needed to keep the cycle going.

Rather than relying on the will of a leader or authority, the Triple-A

Approach should be anchored on human rights. This anchor

automatically identifies the duty bearers as managers and the

claim holders as the centre of their own development. The Triple-A

Approach should be done at multiple levels and should involve and

empower the communities to contribute to their own nutrition

improvement.

African Union Nutrition Champion

SUN Movement Global 2014 Gathering

Global Attention on Nutrition—ICN2

Ethiopia and Uganda Multisectoral Nutrition Policies and Programmes

Regional Consultation Emergency Food Security and Nutrition Preparedness and Response in the Horn of Africa

From the Regional Director

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For this to work, however, there is a critical

need for capacity. Assessment, analysis and

actions all require capacity by local actors,

and we have to be aware that for monitoring

systems to work, they have to be based on

strengthening of local capacities and not

remain a matter of refined procedures at

national and international levels.

Communities and societies are complex

systems that are not fully predictable, but

explainable at points in time. In the face of

changing situations and contexts, it is

important to monitor as closely as possible

using key indicators and iterative planning,

so that revisions and adaptations of plans

throughout succeeding implementation

cycles and learning loops are built into the

system. Monitoring should continuously

provide real-time data for immediate and

ongoing decision-making from key decision

makers, thereby enabling a Triple-A

approach to monitoring, learning and

adaptation.

The knowledge from the past two decades in

nutrition has taken us from implementing

relatively simple solutions and nutrition-

specific interventions to a re-emphasis of the

multisectoral approach to nutrition

programmes. We can reduce stunting by

approximately 20% with nutrition-specific

interventions, but we need to also influence

the other 80%. That can be achieved through

nutrition-sensitive approaches and an

enabling environment together with other

sectors such as agriculture, social protection,

and education.

Bjorn Ljungqvist is an independent consultant who

was instrumental in defining the Strategy for

Improved Nutrition of Children and Women in

Developing Countries as a UNICEF policy in 1990.

Four years since the start of the Scaling Up

Nutrition (SUN) Movement, much progress

has been achieved globally. There are now

54 SUN countries, 17 of them from Eastern

and Southern Africa. Political attention to

nutrition has increased; multi-stakeholder

platforms are in place in most of the SUN

countries and aligning support to

governments; financial commitments for

nutrition have increased; and many countries

are intensifying their efforts to scale up high-

impact, evidence-based nutrition

interventions. In Eastern and Southern

Africa, however, stunting in under-five

children continues to be a significant

bottleneck for children to realize their full

potential. An estimated 28 million or close to

39% of children under-five are stunted (ranging from 29% in Namibia and Angola to

58% in Burundi). The stunting prevalence has changed very little over the past 20

years.

It is with this in mind, that the Eastern and Southern Africa Regional Management

Team has endorsed stunting reduction as one of the programmatic priorities for our

region in the period 2014-2017. The strategies that will be key for reducing stunting

include policy advocacy; national, regional and continental partnerships; scaling up

of proven interventions; capacity development; communication for behaviour and

social change; evidence generation and knowledge sharing; and South-South

cooperation. These strategies will be applied to programmatic focus areas of infant

and young child feeding; addressing micronutrient deficiencies; management of

severe acute malnutrition; and sanitation and hygiene. Ensuring programmes across

the region produce the greatest impact, achieve the best possible results and make

optimal use of resources entails regular performance monitoring.

I hope that you find this edition of the Newsletter useful and informative, as we

continue our collective actions to help deliver results for children in Eastern and

Southern Africa.

Leila Pakkala

Regional Director

Eastern and Southern Africa

UNICEF Eastern and Southern Africa

Regional Management Team has

endorsed stunting reduction as one of

the programmatic priorities for our

region in the period 2014-2017.

From the Regional Director

Triple-A

Approach

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The African Regional Nutrition Strategy (ARNS) 2005-2015 was

adopted in 2005 as Africa’s contribution to the achievement of the

Millennium Development Goals. The task of revising the ARNS was

assigned to UNICEF during the 5th Meeting of the African Task

Force for Food and Nutrition Development (ATFFND), which was

held in Maseru, 29-30 July 2013.

During the 6th ATFFND Meeting in Nairobi, 14-15 May 2014,

UNICEF consultant Bjorn Ljungqvist presented the progress made

in revising the ARNS, based on consultations with Regional

Economic and Health Communities, UN agencies, development

partners and other stakeholders.

Whereas ARNS 2005-2015 focused on development frameworks

and nutrition programme operational strategies, the revised ARNS

2015-2025 represents a paradigm shift towards positioning the

African Union Commission (AUC) as an implementing institution,

and promoting execution of existing frameworks rather than

developing new ones. It is consistent with the AUC’s vision and

mission statement and is aligned with the AUC Strategic Plan 2014-

2017 as it applies to nutrition issues in Africa.

ARNS 2015-2025 articulates the following roles for the AUC: 1)

defines standards, norms, policies and frameworks for AU Member

State adoption and ratification; 2) convenes and facilitates

consensus on issues related to nutrition security; 3) advocates and

promotes implementation; and 4) establishes an architecture for

decision-making. These actions would then lead to the desired

outcomes of having AU Member States adopt, ratify and

domesticate norms; creating an enabling environment; providing

essential services; and establishing good nutrition governance.

These outputs and outcomes would then lead to the overall ARNS

impact objective of contributing to the global World Health

Assembly 2011 targets for nutrition that are to be achieved by

2025.

The participants of the meeting upheld ARNS 2015-2025 as a high-

level strategic document that is in line with the strategic vision of

the AUC for an integrated, prosperous and peaceful Africa that is

driven by its own citizens, and represents a dynamic force in the

global arena.

ARNS is now being taken forward for final validation by the AUC.

Recently appointed African Nutrition Champion, His Majesty King

Letsie III of the Kingdom of Lesotho pressed African governments

to commit resources to their nutrition plans to allow them to reap

the benefits of investment in nutrition. The King made the call

during a breakfast meeting held on the sidelines of the 23rd

African Union Heads of State

and Government Summit

under the theme,

“Strengthening Advocacy for

Improved Nutrition and

Inclusive Development”, in

June 2014, Malabo,

Equatorial Guinea.

“Investing in nutrition is an

investment in the social and

economic development of the

continent,” said the King,

emphasizing that “poor

nutrition is closely linked to

extreme poverty, and improving nutrition is a prerequisite for

reaching the targets of the Millennium Development Goals,

especially those related to education and health”.

“This places a heavy burden on us to work hard, in collaboration

with stakeholders outside nutrition, in order to see positive results

on economies of African countries,” added His Majesty.

“Investing in nutrition will greatly improve productivity, economic

growth, and will promote education, intellectual capacity and the

social development of people,” said Dr. Mustapha Sidiki Kaloko,

Commissioner for Social Affairs of the African Union Commission.

“The nutritional status of a child is influenced by three broad

factors: intake of quality food, health and care,” said Dr. Noel

Marie Zagre, Regional Nutrition Advisor for UNICEF Eastern and

Southern Africa. “The programmes that address malnutrition

therefore have to be multisectoral and multi-stakeholder.”

Revision of African

Regional Nutrition

Strategy

African Union

Nutrition Champion

urges African Leaders

to Invest in Nutrition

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During this AU Summit, the Heads of State and Government of

the African Union went on to make a Declaration on Nutrition

Security for Inclusive Economic Growth and Sustainable

Development in Africa. In this Declaration, governments made a

commitment to end child stunting, in particular, focusing on the

first 1000 Days as the only window of opportunity during which

permanent and irreversible physical and mental damage would

be avoided; position this goal as a high-level objective in national

development plans and strategies; and establish long-term

targets that give all children equal chance for success, by

eliminating the additional barriers imposed by child under-

nutrition.

In October, during the celebration of the 5th Africa Day for Food

and Nutrition Security (ADFNS) held in Kinshasa, Democratic

Republic of Congo, the King recalled the Malabo Declaration on

Nutrition Security and urged the countries to commit to concrete

actions including demonstrating leadership in ensuring the

development of a common results framework for each Member

State; institutionalizing a monitoring dashboard; setting up of a

parliamentarian committee to engage on nutrition issues;

establishing a separate budget line specific to nutrition

interventions; and organizing a sustainable network of

community workers to deliver nutrition services.

The King reminded the participants that the annual celebration of

the ADFNS serves as a timely reminder of governments’

responsibilities toward infants and young children as set out in

Article 14 of the African Charter on the Rights and Welfare of the

Child and Article 24 of the Convention on the Rights of the Child

that recognize the right of the child to the enjoyment of the

highest attainable standard of health.

Fifty-four countries, home to half the world’s malnourished

children, have joined the Scaling Up Nutrition (SUN) Movement.

The annual Global Gatherings for the movement provides an

opportunity for SUN countries and networks to share progress,

learn from each other and be inspired to achieve even more. This

year, the Global Gathering was held in Rome in advance of the

Second International Conference on Nutrition (ICN2). The 300

delegates from the SUN Movement countries, networks and the

Lead Group participated in the gathering.

Plenary and parallel sessions included discussions on the four

Communities of Practice (COP). UNICEF ESARO’s contribution was

acknowledged particularly for COP 1 - Planning, Costing,

Implementing and Financing Multisectoral Actions for Improved

Nutrition during the November 2013 Workshop on Costing and

Tracking Investments in Support of Scaling Up Nutrition; and COP

3 - Reliable Monitoring of Progress, Evaluation of Outcomes and

Demonstration of Nutrition Results during the May 2014

Workshop on Monitoring Implementation and Demonstration

Results. These meetings have become the key milestones to kick-

start discussions on how national, regional and global partners

can respond and build capacities.

The Second International Conference on Nutrition (ICN2) was held in Rome, Italy, 19-21 November 2014. ICN2 was a high-level intergovernmental meeting, focusing on galvanizing global attention to tackle malnutrition over the coming decades with a view to achieving the global nutrition targets agreed upon at the World Health Assembly by 2025. ICN2 was jointly organized by FAO and WHO, in cooperation with IFAD, IFPRI, UNESCO, World Bank, WTO, WFP, the High Level Task Force on the Global Food Security Crisis (HLTF) and UNICEF. Over 2,200 participants attended the meeting, including representatives from more than 170 governments, 150 from civil society organizations and nearly 100 from the private sector.

During the conference, the Rome Declaration on Nutrition and the Framework for Action were endorsed by the participating Heads of State and Government, committing world leaders to redouble political commitment and social participation to improve nutrition; align policies that impact nutrition across different ministries; increase responsible and sustainable investment in nutrition; and establish national policies aimed at eradicating malnutrition and transforming food systems to make nutritious diets available to all.

SUN Movement

Global 2014

Gathering

Global Attention on

Nutrition—ICN2

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Results-Based Management (RBM) is a management

approach focused on defining, measuring, and achieving results

(see illustration for definition and phases of RBM). Monitoring is

measuring and tracking what is happening to the programme and

the context. Monitoring (both performance monitoring and

situation monitoring) thus provides accountability for

implementation, improves programme implementation, and

triggers rapid adaptation of programme response (particularly in

crises or unstable contexts). The “dashboard” is a tool for

performance monitoring and management that can provide a

visual representation of performance measures, ensure total

visibility of key performance indicators, save time compared to

generating multiple reports, readily identify and correct negative

trends in performance indicators, and enable informed decisions

based on real-time data.

The workshop allowed participants to understand the concept of results-based monitoring and get practical guidance on data collection; analysis and performance measurement; feedback and use of information; and building systems that contribute towards a country “dashboard” for tracking implementation rates. Members of the SUN Movement Networks presented options for partners to support countries through Communities of Practice (COPs) during a panel discussion.

The country teams attending the Workshop identified steps needed to improve their information and monitoring systems and for what external expertise might be required. These two sets of needs fell under three broad working areas: 1) development, agreement and use of a common results framework for nutrition; 2) systems strengthening for quality data collection and

management; and 3) capacity building for cross-sectoral analysis, interpretation and use of data. These needs were further discussed during the panel discussion wherein representatives from the Maximising the Quality of Scaling Up Nutrition (MQSUN) Consortium, Global SUN Business Network, SUN Global Civil Society Network, SUN UN Systems Network and the SUN Donor Network affirmed their support to countries on monitoring and evaluation.

In closing, participants were reminded to consider changing situations and contexts in nutrition programming and the importance of close monitoring of key indicators and use of iterative planning so that revisions and adaptations of plans throughout the implementation are built into the system.

Monitoring Implementation and

Demonstrating Results Workshop The Workshop, organized by UNICEF on behalf of the UN Scaling Up Nutrition (SUN) Network was held in Nairobi, 12-13 May

2014. The aim was to strengthen country capacity for results-oriented monitoring of nutrition programmes towards improved

performance, accountability and learning. There were 72 participants, 43 from 14 countries in Eastern and Southern Africa and

29 regional and global partners and resource persons.

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Evidence-based programmes usually include a strong theoretical

foundation for specific target populations (i.e., articulating a

theory of change and specifying the rights holders), identification

of active agents of change (duty bearers), specification of

necessary activities and organizational support (investments),

quality data collection and procedures (monitoring), and evidence

of effectiveness (evaluation). The framework for programming

excellence includes accountability for resources and results with

feedback loops and action between the activities of strengthening

the situation analysis, improving programme design and execution,

and stronger measurement and reporting. The framework for

programming excellence includes accountability for resources and

results with feedback loops and action between the activities of

strengthening the situation analysis, improving programme design

and execution, and stronger measurement and reporting.

Monitoring should continuously provide real-time data for

immediate and on-going decision-making from key decision

makers; thereby applying the Triple-A Approach (Assess, Analyse

and Act) to monitoring, learning and adaptation. For this to work,

however, there is a critical need for capacity by local actors and an

understanding that monitoring systems are based on

strengthening local capacities rather than refining procedures at

national and international levels.

EU-UNICEF

Africa’s

Nutrition

Security

Partnership

To fight the widespread and growing problem of undernutrition,

the EU and UNICEF have been working in partnership on the

Africa’s Nutrition Security Partnership (ANSP) to improve nutrition

security among women and young children in the continent.

ANSP is a four-year programme (2011-2015) that integrates and

positions nutrition security within the African development

agenda and focuses on improving nutrition security among

women and young children in Africa. The Partnership provides

technical advice as well as actual programme implementation

support including capacity building and systems development in

the four countries.

The Annual Review of the implementation held in Addis Ababa,

14-15 October 2014, aimed to assess achievements, challenges,

and lessons learned during the third year of implementation, as

well as to discuss improvements in the implementation for the last

year of the ANSP. The Meeting also presented the ANSP Global

Logframe which was revised based on recommendations from the

last ANSP Annual Review Meeting held in Entebbe, Uganda, 8-10

April 2014.

Progress in ANSP implementation in the last three years in the

four key result areas include:

Result Area 1: Up-stream policy development and nutrition

security awareness: The increased awareness on nutrition security

has resulted in an improved and enabling political environment

where continental, regional and national policies are aligned

towards improving the nutrition situation of women and children

by integrating nutrition across multiple sectors. The draft African

Regional Nutrition Strategy (ARNS) and sub-regional nutrition

frameworks and strategies emphasize leadership, accountability

and multisectoral coordination in order to achieve results. The

four focus countries - Burkina Faso, Ethiopia, Mali and Uganda -

have developed national nutrition plans and policies that highlight

the multisectoral nature of undernutrition and the solutions

therein.

Result Area 2: Institutional development and capacity building:

Strong strategic, managerial and technical capacities are being

developed in countries based on extensive gap assessments on

human resource need for nutrition. Technical training modules are

being developed for Eastern and Southern and West and Central

African countries that will be applicable to pre- and in-service

nutrition training as well as for nutrition-sensitive sectors. Work

being led by Cornell University is breaking new ground in defining,

understanding and documenting how multisectoral nutrition

systems are built in the face of changing contexts and the need for

adaptability.

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Result Area 3: Data analysis and knowledge sharing: National

information systems such as the Annual Nutritional Surveys using

Standardized Monitoring and Assessment of Relief and

Transitions tools (SMART Surveys) in Burkina Faso and Mali, the

Integrated Supportive Supervision and Monitoring System in

Ethiopia, and the Annual Food Security and Nutrition Assessment

in Uganda are being implemented with relevant information

available at all levels for decision-making. At regional and

continental levels, the completion of the technical work behind

the NutritionInfo web-based database will allow ANSP to come

back to discussions with the AUC on how best this standardized

nutrition information database can support monitoring systems

at the continental level.

Result Area 4: Scaling up interventions: Multisectoral nutrition

programmes are being implemented at the community level in

ANSP focus areas where multisectoral coordination structures

are in place to ensure that communities, families, mothers and

children have access to quality nutrition-specific and nutrition-

sensitive interventions. Information from monitoring systems in

these countries are already showing improvements in coverage

rates, behaviours and nutritional status. ANSP will continue to

adjust programmes in order to address identified bottlenecks in

specific areas.

The communication initiatives in the first three years of the ANSP

have provided good visibility for the joint partnership between

the EU and UNICEF. Moreover, they have helped increase the

political commitment and strengthen dialogue on nutrition

security among key counterparts. To date, a significant amount

of work has been completed to raise awareness about the ANSP,

and the support of the European Union. UNICEF has promoted

the EU-UNICEF ANSP Partnership via a web portal featuring

multimedia packages, video and still photography, and has

actively engaged partners.

Presentations from each of the country delegations highlighted

community-based scaling up of nutrition interventions being

implemented in the country. Each country explained the context

in the ANSP focus areas; the multisectoral interventions being

implemented; the management and governance structures at the

community, regional and national levels and how they interact;

how monitoring and evaluation information feeds into the

governance and adjustment of the programme; some key results

achieved; the sustainability of the programme; and, lessons

learned and challenges. This horizontal learning enabled the

countries to discuss details of success factors in the ANSP focus

areas.

Overall, the project components are progressing as planned. In

the last year of implementation, the ANSP focus countries will

continue supporting the implementation of community-based

nutrition programmes, reinforcing multisectoral collaboration at

district and national levels, and strengthening systems

development to increase coverage of nutrition-specific

interventions and nutrition-sensitive development in order to

consolidate achievements from the past three years. An external

Endline Evaluation will be executed by ETC Nederland BV before

the end of Year 4 of ANSP implementation. The Annual Review

Meeting concluded with a commitment from all stakeholders to

continue to critically appraise progress and work towards

identified results.

The Four Pillars of the Partnership:

1. Up-Stream Policy Development & Nutrition

Security Awareness. National policies are aligned

to impact nutrition by integrating nutrition as a

key objective across different sectors.

2. Institutional Development and Capacity Building.

National nutrition programmes are strategic and

have the capacity to adapt to changing contexts

that influence nutrition programming in the

country.

3. Data Analysis & Knowledge Sharing. Strong

national oversight for nutrition with relevant and

sustainable nutrition information systems

available at all levels for decision-making.

4. Scaling Up Interventions. Communities, families,

mothers and children in focus areas have access

to quality nutrition-specific and nutrition-

sensitive interventions.

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Eastern and Southern

Africa Regional

Priorities

Within the framework of the UNICEF Strategic Plan 2014-2017,

the UNICEF Regional Management Team identified five

programmatic priorities to focus cross-country action, learning

and reinforce joint accountability:

Enabling children to survive and thrive.

Reducing stunting to provide opportunities for children to

realize their full potential.

Improving education quality and learning outcomes to

prepare children for the future.

Achieving results for adolescents (R4A) that help them

manage risks and realize their full potential.

Scaling up social protection interventions to reduce child

poverty and other vulnerabilities that impede the full

realization of child rights.

These regional priorities will provide the basis to focus investment

and resources on selected critical actions and interventions that

have the highest potential for scaling up and delivery of equitable

results for children. The regional priorities reinforce, rather than

replace, the country-specific priorities outlined in country

programme documents and agreed with national counterparts,

and articulate what the UNICEF Eastern and Southern Africa team

will contribute as a region to the achievement of organization-

wide Strategic Plan results.

David Pelletier, Associate Professor of Nutrition Policy in the

Division of Nutritional Science and Suzanne Gervais, Sr. Extension

Associate, both at Cornell University, are the Principal

Investigators for the work on Strategic Capacity and Adaptive

Management of Multisectoral Nutrition Policies and Programmes

in cooperation with UNICEF.

The African’s Nutrition Security Partnership (ANSP) is an EU-

UNICEF collaboration that seeks to reduce stunting in four focus

countries—Burkina Faso, Ethiopia, Mali and Uganda—by

strengthening the enabling policy environment for multisectoral

approaches and operationalizing multisectoral policies and plans

in selected regions or districts in these countries. Cornell

University has been engaged to support ANSP stakeholder efforts

in these four countries and to document the lessons emerging

Building Strategic

Capacities

from the development and operationalization of multisectoral nutrition at national and sub-national levels for dissemination within and beyond these countries. Below is an excerpt from an interim brief written at an early stage of Cornell’s engagement with the ANSP countries. The full brief can be obtained from David Pelletier: dlp5@cornell.edu.

A Framework for the Multisectoral Nutrition

System

Although there is now an abundant supply of agency guidance

documents on multisectoral nutrition and a growing number of

national multisectoral nutrition plans, there does not yet appear

to be a clear or shared understanding of how to operationalize

this approach at country level. This is the case in the four ANSP

countries, where a common remark is “this is all new and we are

learning as we go,” and stakeholders with broader regional

responsibilities indicate that it is also true in other countries on

the continent. It is in this context that the ANSP stakeholders

appreciated a visual representation of a multisectoral nutrition

system that the Cornell team created based on the early

observations in the ANSP countries and previous experience. This

representation uses a land cruiser as a metaphor. The nutrition

system, like this metaphor, includes seven interacting elements,

all of which are required for sustainable and effective

functioning: a clear purpose, components and connections,

alignment, fuel, designers and engineers, servicing and repairs

and resources.

Early observations from the ANSP countries indicates that a great

deal of attention is given to the creation of coordination

structures for implementing multisectoral nutrition system

policies and plans, and there is a clear recognition that a great

deal of work is needed to make these structures functional. What

has been lacking, however, is a clear sense of the priority

activities needed to make them functional. When all the

elements of the land cruiser metaphor are integrated (see

illustration), it provides a simple visual reminder of some of these

crucial issues and the sequence for tackling them.

While this system illustration does signal what issues need

attention when building or operationalizing a multisectoral

nutrition system it does not by itself provide a clear sense of how

to address these various issues. For instance, while “alignment”

among government and non-government actors is important, the

illustration does not indicate how this can be achieved in

practice. Similarly, “consistent incentives” is noted but the

illustration does not indicate how to create these in various

contexts. A prominent example of the latter is when there may

be real or perceived competition or conflict between nutrition

goals and the long-standing goals and incentives in a ministry.

Answering the “How” question on these issues, in very concrete

and practical ways, is an important part of the Cornell’s learning

agenda in the ANSP countries, as in all the SUN countries.

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This system lens reveals the magnitude of the challenge in

operationalizing a multisectoral nutrition system. When applied to

the ANSP countries this lens reveals some important variations in

the design of the multisectoral nutrition structures and a small

core of dedicated individuals advancing the work who have taken

on multisectoral duties in addition to their usual duties. Success is

likely to require an expanded core team at the national level, an

appropriate time horizon and a realistic set of political

expectations in order to provide the space for high quality work.

The system lens also reveals a need to address an “alignment gap”

at country level and a “dissemination gap” from global to country

level, both of which need attention in the early stages of the

multisectoral nutrition system effort.

Finally, the application of a systems lens highlights the

extraordinary importance and downstream consequences of the

seemingly routine “busy work” involved with building a

multisectoral nutrition system. This last observation suggests a

need for greater attention, support and recognition for seemingly

routine activities in order to ensure the highest possible quality

and to enable the updating of the design and implementation of

multisectoral nutrition system policies and interventions based on

experience. Additionally, strategic capacities and adaptive

management must be strengthened to facilitate stronger

alignment and continued progress on the multisectoral agenda at

national and sub-national levels.

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Focus on Ethiopia and Uganda: Strategic

capacity and adaptive management of

multisectoral nutrition policies

FAO, UNHCR, UNICEF AND WFP Regional

Consultation—Emergency Food Security and

Nutrition Preparedness and Response in the

Horn of Africa

Background On 25–26 September 2014, representatives of FAO, UNHCR, UNICEF and WFP country teams from Djibouti, Eritrea, Ethiopia, Kenya, Somalia, Sudan and Uganda and the respective regional offices and OCHA met in Nairobi, Kenya, to discuss the current situation and joint approaches towards food security, nutrition and refugees situation in the Horn of Africa. The first day of the meeting started with an overview of the region, followed by rich discussion and exchange of ideas among the participants. The results of the regional consultation were then shared with the donor community and peer organizations on the second day of the meeting. Regional nutrition and food security overview The current situation is not an acute regional food and nutrition crisis

(as in 2011) and yet the situation is urgent, with all eight countries (including South Sudan) in a state of chronic crisis with pockets of acute food insecurity and emergency-level malnutrition. Deeply embedded vulnerability, with chronic, long-term food insecure and malnourished populations continues to be the dominant factor. Across the region, more than 12 million people are in emergency or crisis food security situations. Key recommended actions At country level:

To finalize preparedness and response country action plans for food security and nutrition programming, that combines humanitarian (short term) and development (medium and long term) actions and promotes resilience by addressing the long-term drivers of vulnerability.

Enhanced inter-agency collaboration and accountability for joint commitments.

Both Ethiopia and Uganda have made great strides in the first year

of implementation of the partnership between UNICEF and Cornell

University in advancing the development of their multisectoral

nutrition approach and in establishing proper structures for the

implementation of the National Nutrition Policy (NNP) in Ethiopia

and of the Uganda Nutrition Action Plan (UNAP) in Uganda.

In Ethiopia, the partnership has played a technical facilitative role

and supported the NNP implementation process especially by

strengthening capacities in the implementation structures at

national and sub-national levels. Furthermore, as requested by the

Government, immediate technical support was provided to the

Nutrition Case Team by contributing to some specific deliverables

such as Terms of References, sections of the Implementation

Guidelines, progress markers, meeting reports and other products.

In Uganda, we have worked at strengthening and supporting the

country-owned, country-led UNAP implementation process;

fostered common understanding and stakeholder appropriation of

UNAP; and at the district level, we have worked on developing a

consensus model for UNAP operations.

The way forward for the partnership in both countries is to

continue supporting the implementation of NNP and UNAP

through building capacities at national and subnational levels; and

to foster learning and common understanding, while capitalizing

on our unique boundary crossing and facilitator roles to continue

stimulating cross-country fertilization by documenting and

disseminating lessons learned.

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Advocacy and support for placing food security and nutrition at the centre of the government agenda.

Improved data collection and data management. At the regional level, a two-year regional support plan (to reinforce country actions) is being drafted. Its priority areas are: (1) Strengthening of Early Warning/Early Actions; (2) Ensuring quality and scale in joint food and nutrition action planning; (3) Supporting the response to refugees; and (4) Resourcing and advocacy. Delivery mechanisms have been identified for each priority as well as a convener and participating agencies. In January 2015, the Regional Support Plan will be disseminated to donors along with a Regional Investment Case that highlights priority areas to support joint advocacy for the food security and nutrition response in the Horn of Africa.

Nutrition Digest A quick overview of selected literature issued monthly

The authors estimated the benefit-cost ratios for nutriton-specific interventions by reviewing the evidence around pathways

in which stunting may generate economic losses though the following: 1) loss in physical growth potential, 2) cognitive

impairments and 3) increased risk of chronic diseases. Despite conservative assumptions used by the authors, all estimated

benefit-cost ratios are >1.0. Estimates ranged from 3.6 in the DRC to 48 in Indonesia, with a median of 18 in Bangladesh.

Hoddinott, J., H. Alderman, J. R. Behrman, L. Haddad and S. Horton (2014). The economic rationale for investing in stunting

reduction. Maternal and Child Nutrition 9 (Suppl 2):69-82

JAN

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The authors examined 44 coverage assessments from 21 countries to identify barriers to access to severe acute

malnutrition (SAM) services and understand how they vary according to context. The analysis found that the five most

commonly reported barriers to access across all interventions were: 1) Lack of knowledge of malnutrition; 2) Lack of

knowledge of the programme; 3) High opportunity costs; 4) Distance to site; and 5) Previous rejection. All the barriers were

found also to have influenced public health programmes.

Puett, C. Hauesnstein Swan, S. and Guerrero, S. (2013). What factors influence access to community-based treatment of

severe acute malnutrition? Access for All, Volume 2: (Coverage Monitoring Network, London, November 2013)

FEB

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The period between 6 and 24 months of age is a critical time in the growth of an infant. Therefore, complementary feeding

(CF) during this period needs to be timely, adequate, appropriate and sufficient in quantity. This study assessed the impact

of CF education on growth among children under 2 years of age and shows that CF education alone significantly reduced

rates of stunting (RR 0.71; 95% CI 0.56 to 0.91). Community-based nutrition education (including home-based dietary

counselling with messages that are culturally appropriate) combined with appropriate CF (utilizing locally available and

affordable nutrient dense foods) are needed to improve the nutritional status of children.

Lassi, Z.S., et al. Impact of education and provision of complementary feeding on growth and morbidity in children less

than 2 years of age in developing countries: a systematic review. BMC Public Health 2013; 13 (Suppl 3): S13.

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Increasing economic growth as a national policy is often justified for improving population health and nutrition in develop-

ing countries on the assumption that increasing per-capita will improve access to and consumption of goods and services

which in turn will improve nutritional status. This study challenges this assumption and emphasizes the need for direct in-

vestments in health and nutrition. Experiences from countries show that reduction in undernutrition can be accelerated

but that this will need deliberate action in prioritizing investment in the scale up of nutrition-specific interventions and

shaping national development processes to maximize nutrition sensitivity.

Vollmer, S., et al. (2014) Association between economic growth and early childhood undernutrition: evidence from 121 De-

mographic and Health Surveys from 36 low-income and middle-income countries. Lancet Global Health 2014; 2: e225-34.

12

In 2013, the World Health Assembly endorsed the Comprehensive Implementation Plan (2012-2025) on Maternal, Infant

and Young Child Nutrition which included a global target for stunting, i.e. to reduce the number of stunted under-five

children by 40% by 2025. In 34 countries that have a high burden of stunting, scaling up the 10 nutrition-specific high

impact interventions to 90% coverage can result in overall reduced stunting by only 20%. Nutrition-specific interventions

alone are almost certainly insufficient; hence the importance of ongoing efforts to foster nutrition-sensitive development

and evidence based, multisectoral plans to address stunting at national scale.

De Onis, M, et al. The World Health Organization’s global target for reducing childhood stunting by 2025: rationale and

proposed actions. Maternal and Child Nutrition 2013; 9 (Suppl 2): 6-26.

MA

Y

This Cochrane review is the first one looking at the impact of WASH interventions (to improve water quality and supply,

provide adequate sanitation and promote handwashing with soap) on the nutritional status of children under the age of 18

years. The review provides evidence that WASH interventions may slightly improve height growth in children under five

years of age. On the basis of both empirical and theoretical evidence, comprehensive WASH interventions that affect the

physical and behavioral environment in which a child grows and plays should continue to play a critical role in the

prevention of early childhood diarrhea and, thereby, in improving child nutrition and development.

Dangour, A.D, L. Watson, O. Cummings, S. Boisson, Y. Che, Y. Velleman, S. Cavill, E. Allen, R. Uauy (2013). Interventions to

improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children

(Review). Cochrane Database of Systematic Reviews Issue 8. Art. No.: CD009382.

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The authors of the two papers have searched through reviews and studies on whether and how agriculture can have

positive benefits for nutrition and health, particularly among mothers and children. The evidence base for the relationship

between agricultural change and improved nutrition is poor. The current lack of evidence does not mean that agriculture

does not support gains in nutrition and health, rather that the evidence of positive impact is still weak. It is critically

important for planners to explicitly include nutrition outcomes and indicators in agricultural programmes so that special

attention can be paid to identifying nutrition outcomes and in considering them during evaluations.

Meeker, J., L. Haddad. A state of the art review of agriculture-nutrition linkages. AgriDiet; 2013. Webb, P. Impact pathways

for agricultural research to improve nutrition and health: Literature analysis and research priorities. FAO and WHO; 2013.

JULY

The authors reviewed the main barriers and enabling factors affecting six types of large-scale maternal nutrition

programmes in field conditions. The six programme types included salt iodization; flour fortification; micronutrient

supplementation; nutrition education, and conditional cash transfers. This study shows that the key elements for

successful scaling up vary in importance depending on the specific maternal nutrition programme and the context in which

it operates. Programme designers need to think ahead about possible critical barriers for a given programme which in turn

can help to prioritize actions. Incorporation of equity considerations and investment in quality monitoring and evaluation

frameworks are also important.

Victora, C. G., et al. Scaling up maternal nutrition programs to improve birth outcomes: A review of implementation issues.

Food and Nutrition Bulletin 2012; 33 (Suppl): S6-26.

JUN

E

Brazil’s Bolsa Familia Programme (BFP), the world’s largest conditional cash transfer (CCT) programme, has already been

shown to effectively reduce stunting and underweight among children under 5 years of age (Paes-Sousa, 2011). The

current study assessed the effect of BPF on under-5 mortality rates – and further reinforces the findings that this CCT

supports nutrition security by concluding that the decrease in mortality rates was largest among the malnutrition-related

deaths. The effect of consolidated BFP coverage was highest on under-5 mortality resulting from malnutrition (RR 0.35;

95% CI 0.24-0.50) followed by mortality resulting from diarrhea (RR 0.47; 0.37-0.61).

Rasella, D., R. Aquina, C.A.T. Santos, R. Paes-Sousa, M.L. Barreto. 2013. Effect of conditional cash transfer programme on

childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet; 382: 57-64.

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13

Among the targets set during the 65th World Health Assembly was a commitment to halve anaemia prevalence in women

of reproductive age by 2025 from 2011 levels. In this study, the authors estimated 1995 to 2011 trends in distribution of

haemoglobin concentration for children aged 6-59 months and for women of reproductive age (15-49 years) by pregnancy

status. In both 1995 and 2011, central and west Africa and south Asia had the lowest mean concentrations of haemoglobin

and the highest anaemia prevalence; east Africa had low haemoglobin concentrations for children. Mean haemoglobin

concentrations declined and anaemia prevalence have increased in children in southern Africa.

Stevens, G. A., M. M. Finucane, L. M. De-Regil, C. J. Paciorek, S. R. Flaxman, F. Branca, J. P. Pena-Rosas, Z. A. Bhutta, M.

Ezzati, on behalf of Nutrition Impact Model Study Group (Anemia) (2013). Global, regional, and national trends in

hemoglobin concentration and prevalence of total and severe anemia in children and pregnant and non-pregnant

women for 1995-2011: a systematic analysis of population-representative data. Lancet Global Health 1: e16-24.

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Worldwide, the prevalence of overweight and obesity combined increased by 27.5% for adults and 47.1% for children

between 1980 and 2013. The proportion of adults overweight or obese increased from 28.8% (95% UI 28.4-29.3) to 36.9%

(36.3-37.4) in men, from 29.8% (29.3-30.2) to 38.0% (37.5-38.5) in women. Among children and adolescents under 20 years

of age, the increase have been from 8.1% (7.7-8.6) to 12.9% (12.3-13.5) in boys and from 8.4% (8.1-8.8) to 13.4% (13.0-

13.9) in girls.

Ng, M., T. Fleming, M. Robinson, et al. (2014). Global, regional, and national prevalence of overweight and obesity in

children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384:

766-81.

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