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April 2010 African Health Ministers’ Conference and
July 2010 AU Heads of State and Government Summit
FOOD AND NUTRITION SECURITY DISCUSSION PAPER1
DRAFT - 12 April 2010
1. The Rising Hunger and Malnutrition Problem in Africa2
The vast and rising numbers of food insecure and undernourished people continue to pose very serious
concerns in Africa. Over the past two years, the global food prices increase followed by economic and
financial crisis has pushed more people into poverty and hunger. Globally, as many as one billion people
are affected, with Africa and Asia contributing to over 80 per cent of the world’s hungry people.
Africa is already home to 216 million people who are undernourished, with 16 countries having 35 percent
or more and 3 countries3 having over 50 percent undernourished population. These affected populations
are particularly vulnerable. Because of the food security challenges poor people are already facing, any
shortages or increases in food prices will have devastating effects on their livelihoods, nutrition and health.
Unfortunately, due to structural reasons, the poorest households are often least prepared to take
advantage of the opportunities created in a growing rural economy or, indeed, of increases in producer
prices. Thus, their situation is at high risk of further deteriorating due to the food and economic crisis, plus
progressive effects of climate change involving severe and recurring droughts/floods, as well as persisting
conflicts, political crisis and poor governance.
The first Millennium Development Goal (MDG1) calls for the eradication of extreme poverty and hunger.
Nutrition status of children under five years of age is one of the key indicators used to assess progress
towards MDG1. The latest data show that out of the 63 developing countries that are on track to reach
MDG1 (Target 1.C)4, only nine are from the African continent (using prevalence of underweight5 as the
indicator for hunger and malnutrition). In the continent as a whole, it represents insufficient progress to
achieve the target. This limited progress is likely to be reversed, unless coherent national strategies are
urgently put into place and fully supported to orchestrate well coordinated and decisive priority actions.
Achievement of MDG1 is crucial for national socioeconomic progress and development. Failing to achieve
it jeopardizes the realization of all the other MDGs, including goals to reach universal primary education
(MDG2), promote gender equality and empower women (MDG3), reduce child mortality (MDG4), and
improve maternal health (MDG5).
1This
paper is initially compiled by Saba Mebrahtu, Regional Nutrition Advisor, UNICEF Eastern and Southern Africa Regional Office, with Bibi Giyose,
Senior Advisor Food and Nutrition Security of the NEPAD Planning and Coordinating Agency, and Cecilia Garzon, Regional Nutrition Advisor, WFP
East and Central Africa Regional Bureau - to be circulated, for review and comments, to the ATFFND (Africa Task Force on Food and Nutrition
Development) of the AU, plus key partners including UNICEF/WFP HQ and other ROs - WCARO/MENA, the EC and DFID.
2 Data on nutrition security is from the June 2009 AU/UNICEF documents entitled “A Snapshot of the nutrition situation in Africa” and “Improving
Nutrition Security for Africa’s Children: The Foundation of Survival and Development,” including latest updates from the November 2009 UNICEF
document entitled “Tracking Progress on Child and Maternal Nutrition: A survival and development priority.”
3 These are Burundi, Democratic Republic of Congo and Eritrea, requiring high priority attention and support to alleviate such significant levels of
hunger.
4This target calls for countries to cut in half hunger and malnutrition between 1990 and 2015
5 Underweight (low weight for age in children under five years of age) is a composite measure of chronic (low height for age in children under five
years of age) and acute malnutrition (low weight for height in children under five years of age).
1
Though use of underweight is important and key to tracking progress towards MDG1, a sole focus on this
indicator can mask the greater percentage of the under-nutrition problem – stunting. UNICEF latest
estimates have revealed that global burden of stunting is even greater than underweight. About 200
million children under five years of age in developing countries are stunted; with Africa and Asia
contributing 90 per cent of these children. In comparison, 130 million children under five years of age are
underweight. Furthermore, many more African countries have much higher rates of stunting prevalence (a
total of 19 countries) compared with underweight prevalence (9 countries). Therefore, the high stunting
burden is of great concern, as a significant and persisting portion of under-nutrition.
2
Stunting is a consequence of chronic nutritional deprivation starting before birth - if the mother is
undernourished before and during pregnancy, and then continues until the child is two years of age. This
very early period in life is most vulnerable to nutritional deficiencies which can have significant, adverse
and irreversible impact on child growth and development. Stunting which occurs in children during this
period in particular is difficult to correct, especially if they live under the prevailing poor environmental,
hygiene, and health conditions of many developing countries. Children are on the other hand, more likely
to catch up from weight loss (underweight), when their nutrition and health improve later in childhood.
These children could then manage to have adequate weight for their age, masking nutritional deprivations
which occurred before and during pregnancy or infancy, which may have impaired their growth and
development.
The consequences of malnutrition in children are profound, far-reaching and irreversible. Malnutrition
contributes to more than 35 per cent of child deaths. It weakens the immune system, making children
more susceptible to diseases, and reducing their chances of surviving illnesses, such as diarrhea,
pneumonia, and malaria. Those children who survive face a cycle of recurring illness and growth faltering,
irreversibly damaging their physical development and mental capacity. As a result, they are less likely to
attend school and perform more poorly than their nourished counterparts. By adulthood they face higher
risk of diseases than those who were not undernourished as children; their capacity to earn a decent
livelihood is diminished and they are less able to care for their children. The vicious cycle of undernutrition and poverty thus often continues across the generations.
Ultimately, the damage of malnutrition significantly imperils progress of African communities and nations,
reducing their economic productivity and growth. The World Bank estimates that malnourished children
are at risk of losing more than 10% of their lifetime earning potential; while this is costing poor countries
up to 3% of their yearly GDP. As such, malnutrition is leading to a significant loss of both human and
economic potential. To this end, improving nutrition status is a priority area needing urgent policy
attention for accelerating socioeconomic progress and development in Africa.
3
Twenty-four countries account for more than 80 per cent (or 195.1 million) of the global burden of chronic
under-nutrition. Half of these countries are in Africa, contributing a total of about 42 million stunted
children to the global burden.
Numbers of Stunted Under-fives
in 12 High Priority Countries in Africa (thousands, 2008)
Nigeria
10,158
Ethiopia
6,768
5,382
DRC
Tanzania
3,359
Egypt
2,730
Uganda
2,355
Sudan
2,305
Kenya
2,269
Mozambique
1,670
Madagascar
1,622
Niger
1,473
South Africa
1,425
0
2,000
4,000
6,000
8,000
10,000
12,000
Source: Multiple Cluster Indicator Surveys (MICS), Demographic Health Surveys (DHS) and other national surveys, 2003-2008.
Children suffering from wasting or acute malnutrition (low weight for height in children under five years of
age), suffer increased risk of death. Half of the 10 countries that contribute to 60 per cent of the global
wasting burden are from Africa, contributing some 7.91 million wasted children to the global burden.
These include: Nigeria (contributing some 3.5 wasted children); Ethiopia (1.7 million); Democratic Republic
of the Congo (1.2 million); Sudan (0.95 million) and Egypt (0.68 million). According to the latest evidence,
10 percent of children in Africa are wasted, with a number of African countries having critical levels of
wasting rates of 10 percent or more.
4
Vitamin and mineral deficiencies are highly prevalent throughout the developing world, including the
African continent. Vitamin A Deficiency (VAD) is a significant public health problem across Africa, Asia and
some of Latin America countries affecting 33 per cent (190 million) of preschool age children and 15 per
cent of women of pregnant women (19 million). Africa and some parts of Asia have the highest prevalence
rates, where more than 40 per cent of pre-school children are estimated to be vitamin A deficient. Iron
deficiency affects about 25 per cent of the world’s population, most of whom are children and women. It
causes anemia, and the highest proportion of pre-school age children with anemia are in Africa (68 per
cent). Zinc and folate deficiencies are also common.
The Costs of Malnutrition versus Benefits of Investing in Nutrition
Despite the strong and overwhelming evidence on the grave consequences and high costs of nutritional
deficiencies in the short-term on survival, growth and development and in the long-term on national social
and economic development, nutrition continues to be grossly neglected. It remains a low priority on the
national development agendas of many countries. This is reflected in the very limited progress seen
towards MDG1 particularly in African. Yet, benefits of investing in nutrition are well known to be highly
significant. Nutrition is the foundation of survival, health, as well as national economic growth and
development; and a prerequisite to the achievement of all the MDGs. Thus investing in nutrition does
make political, economic and social sense.
A group of Nobel Laureates6 in economics recently ranked a series of core and proven nutrition
interventions among the most cost-effective solutions to global development challenges, including
Micronutrient supplementation (Vitamin A and zinc), micronutrient fortification (iron and salt iodization),
de-worming, nutrition programs at school and community-based nutrition programs. The per capita cost
of these interventions is estimated at less than US$10; with relatively quite high cost: benefit ratio. A
global investment of US$ 60 million per year for Vitamin A and zinc supplementation, for instance, would
yield in benefits of US$ 1 billion.
It is now clearly evident that a continued lack of attention to maternal and child nutrition will result to
significant losses of human potential capacity and economic growth, ultimately leading to further
economic stagnation of African national economies and immense suffering of its population. High level
leadership and commitment is needed on food security and nutrition, as integral part of a wider national
development agenda on poverty elimination, accelerated and sustainable agriculture development that
will help to fast track progress towards achievement of MDG1 in Africa. With only five years left remaining
to 2015, a massive and concentrated effort is needed as a matter of high priority and urgency.
2. The Causes of Malnutrition and the Significance of Nutrition Security
Household food security is an essential key requirement to achieve optimal nutrition but it is not sufficient.
Nutrition security is especially important during early period of life between -6 to 24 months, as this is
most vulnerable to nutritional deprivations, with detrimental and profound effects on survival, health and
development. Nutrition security implies more than just access to adequate quantities, but of safe and a
variety of good quality foods (including micronutrients) and improved dietary intake. It requires optimal
household and community practices in child care, and access to key social services to prevent and control
acute malnutrition and diseases. These include access to quality health-care services (e.g. Immunization,
early detection and management of acute malnutrition, nutritional management illnesses etc), access to
safe water, hygiene and sanitation, environmental health, hygienic and safe food preparation practices.
Food and nutrition security is achieved when adequate food (quantity, quality, safety, sociocultural
6
‘Hunger and malnutrition: Copenhagen Consensus Challenge paper’, 2008, by S. Horton, H. Alderman, J.A. Rivera, the Copenhagen Consensus
Center, Denmark. Available at www:copenhagenconsensus.com/Default.aspx?ID=1149.
5
acceptability) is available, accessible, and satisfactorily used and utilized by all individuals at all times to
live a healthy and active life, and when good quality care exists and health care services are available.
Furthermore, a number of key inter-related underlying and basic political and societal factors also
influence nutritional status of individuals, communities and populations - including disparities and gender
power relations which will influence household and individual access to resources. Particular attention
should be given to poverty, inequity, maternal education and social status, as well as use of gender
disaggregated data. Analyzing disparities in equity can lead to a better understanding of the causes of
under-nutrition and can help identify and target interventions for the most vulnerable populations within a
country or region as part of a multi-sectoral nutrition strategy.
Since nutrition is very multidimensional in nature, it thus requires a comprehensive approach whereby
all the key sectors play their part.
The core indicators and threshold of nutrition security in infants and young children, the most vulnerable
population group, include wasting prevalence of 10% and above, stunting prevalence of 30% and above,
under-five mortality rate of 100/1,000 live births and above, low rates of early breastfeeding initiation,
exclusive breastfeeding up to 6 months, continued breastfeeding at one year of age, introduction of
complementary foods at 6-8 months, and minimum dietary diversity7, while the underlying factors of
malnutrition, such as health status and household food security are explanatory elements.
3. Drawing from Existing Best Practices and Lessons
The situation in Africa is not all doom and gloom – there is some ray of hope that with focused and
strategic interventions the situation can be reversed. Even though progress is insufficient in Africa to meet
the MDG1 target and there are serious concerns of a worsening situation, it is worth taking note of
significant improvements that have been made by several countries. It is also worthwhile to review
selected existing country experiences, where dramatic increases on core specific nutrition interventions
have been seen (such as exclusive breastfeeding, Vitamin A supplementation, household access to iodized
salt and other food fortification initiatives, management of severe acute malnutrition, and social
protection). It is important to distill the best practices and lessons, for possible use as inputs into future
refinement of the existing strategies, and further improvements, deepening and expansion of ongoing food
security and nutrition programs.
Eleven African countries have reduced underweight prevalence by more than one third since 1990. With 5
out of these countries - Algeria, Congo, Ghana, Mauritania and Sao Tome and Principe, reducing
dramatically their underweight prevalence by more than one-third. These country experiences show that
it is entirely feasible to scale-up nutrition programmes to achieve marked improvements, especially when
there is strong government leadership and a broad-based supporting partnerships.
7
UNICEF/WHO 2008. Indicators for assessing infant and young child feeding practices: Part 1 Definitions. Geneva: World Health Organisation
6
Source: UNICEF global database
Note: Prevalence based on NCHS reference population
However, even more progress is needed in Africa as a whole, where decline in underweight prevalence has
been limited, with 28 percent of children under-five years of age being underweight around 1990,
compared with 25 percent around 2008. Africa has shown the least decline in underweight, as compared
to other regions in the developing world, such as Asia.
As mentioned before, even in countries where underweight prevalence is low, stunting rates can be
alarmingly high. For instance, in Egypt and Swaziland underweight prevalence is at 6 and 5 percent,
respectively, whereas stunting rate is 4-5 times higher (it is at 29 percent in both countries). In the
continent as a whole, a greater proportion of children are affected by stunting than underweight; 40
percent of children under-five years of age are stunted compared to 25 percent underweight.
Also in comparison to underweight, where improvements have been seen in some 11 countries, only two
countries (Eritrea and Mauritania) have seen significant stunting reduction. In Eritrea, this declined from
66 percent to 38 percent and in Mauritania from 57 percent to 27 percent from around 1990 to around
2008, respectively. It means that the core evidence-based interventions to reduce stunting need further
strengthening and/or expansion, in particular improved maternal nutrition before and during pregnancy
and optimal complementary feeding up to two years of age.
7
Exclusive breastfeeding for the first six months of life is key to reducing illness, especially diarrhoea and
acute respiratory infections - two leading causes of infant death. Latest Lancet estimates have shown that
8
exclusive breastfeeding can reduce child deaths by 12 percent . Furthermore, studies have shown that
breastfeeding is crucial for neurological, cognitive and behavioural development; while it has additional
health benefits for women (e.g. reduced breast cancer rates). In nineteen African countries, exclusive
breastfeeding has increased by at least 20 percent over the last decade; with five of these countries –
Rwanda, Madagascar, Zambia, Malawi and Ghana, achieving more than 50 percent exclusive
breastfeeding rate. Recent country studies, in five countries in Africa (Benin, Ethiopia, Ghana, Madagascar,
and Mali), in addition to others in Latin America9, have demonstrated the feasibility of improving
breastfeeding practices through implementation at scale of a comprehensive approach, including scale-up
of a carefully developed and evidence-based ‘behaviour change’ communication programme with focused
and actionable messages, and support and protection of breastfeeding. These country studies, also
showed the importance of community-based activities and the role of communities as partners and not
recipients of services. Most recently, Kenya has demonstrated substantial increase in exclusive
breastfeeding rate based on preliminary data from 2008. The programme in Kenya is based on a
comprehensive, multi-level approach improving exclusive breastfeeding rates that have proven successful
10
in the above cited countries from Africa and elsewhere . However, accelerated progress is needed; the
majority of countries in Africa still have exclusive breastfeeding rates below 50 per cent. While as many as
70 per cent of infants in Africa face greater risk of morbidity and mortality due to non-exclusive
breastfeeding.
Z. A. Bhutta, et al. 2008. ‘What works? Interventions for maternal and child under-nutrition and survival’, The Lancet, 371:9610:417-440.
WHO. 2008. “Learning from large-scale community-based programs to improve breastfeeding practices’, Geneva,
WHO/UNICEF/AED/USAID/Africa’s Health 2010.
10 UNICEF Kenya Country Office, ‘Annual Report 2008’ (internal document), cited in UNICEF, 2009 (ibid).
8
9
8
It is now well established since over a decade that vitamin A supplementation (VAS) of children under five
at risk of vitamin A deficiency can reduce mortality from all causes by 23 percent.11 Recent studies from
Nepal12,13 and Indonesia14 have since confirmed the beneficial effects of VAS on mortality and malnutrition
reduction in children. This has been further supported by a recent Lancet series on child survival, which
identified VAS as one of the key proven interventions to reduce child mortality.15 Achieving universal
coverage of twice-yearly VAS is thus a key step towards meeting the MDG4 goal for child survival. In
Africa
full protection with two doses of VAS doubled between 2001 and 2008 – from 39 percent to 74 percent by
2008. Child Health Days (CHDs), a twice-yearly cycle of preventive services defined by local circumstances
19 African countries where exclusive breastfeeding has increased at least 20 per cent
Percentage of infants 0-5 months old exclusively breastfed
Source: UNICEF Global Database
100
88
83
80
67
60
54
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40
20
34
21
17
14
7
1
1
22
23
24
14
10
3
34
36
28
10
36
38
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41
57
61
44
43
38
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and epidemiological needs, have played a prominent role to dramatically increase VAS coverage to
children. In addition to VAS, CHDs have invariably included an integrated package of high impact
interventions such as de-worming, immunization, malaria prevention, nutrition education, promotion of
key family care practices and antenatal care. They build on primary health care infrastructure and staffs,
using a locally appropriate combination of fixed sites, outreach primary health care staff and other
approaches16. A multi-country evaluation17 in six Eastern and Southern Africa Region (ESAR) countries –
Ethiopia, Madagascar, Tanzania, Uganda, Zambia and Zimbabwe – showed that CHDs achieved coverage
11
G. Beaton, et al., 1993, ‘Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries’,
ACC/SCN State-of-the-Art Series, Nutrition Policy Paper, No. 13.
12 Thapa, S., M. Choe and R. Retherford. 2005. ‘Effects of vitamin A supplementation on child mortality: Evidence from Nepal’s 2001 Demographic
and Health Survey.’ Tropical Medicine & International Health. 10(8):782-789.
13 Bishai, B. et al. 2005. ‘The impact of vitamin A supplementation on mortality inequalities among children in Nepal.’ Health Policy and Planning.
20(1):60-66.
14 Berger, S. et al. 2007. ‘Malnutrition and morbidity are higher in children who were missed by periodic vitamin A capsule distribution for child
survival in rural Indonesia. J. Nutr. 137:1328-1333.
15 G. Jones, et al., 2003, ‘How many deaths can we prevent this year?’ The Lancet, 362:65-71.
16 Life Beyond NIDs: Harnessing regular health services to protect all children against vitamin A deficiency: A summary of the findings and
recommendations of missions to assess vitamin A supplementation programs in twenty countries’ (draft), undertaken jointly by UNICEF and
Micronutrient Initiative. Available at: www.micronutrient.org/pdfs/Life_beyond_NIDs.pdf.
17 UNICEF ESARO, 2008, ‘Multi-country evaluation of Child Health Days in Eastern and Southern Africa: Part 1 – Overview’, Nairobi, United Nations
Children’s Fund Eastern and Southern Africa Regional Office.
9
above 80 percent of twice-yearly vitamin A supplementation, with coverage increases from 15 to 90
percentage points. To date, practically all countries in ESAR have adopted CHDs to deliver VAS twice
yearly to children, along with other high impact interventions. Most countries in West and Central Africa
have elaborated national guidelines for VAS programs; this has helped to mainstream VAS activities into
health and community-based systems.18 Based on existing evidence on efficacy, child mortality rates are
expected to fall in the countries that have increased vitamin A supplementation.
Continued progress is needed to use innovative approaches to reach the remaining hard-to-reach children
(over 30 million), that remain unprotected from increased risks of morbidity and mortality due to Vitamin
A deficiency. Plus, progress is needed to sustain this approach by institutionalizing CHDs and their full
integration into routine health services, building on the ongoing country experiences across the continent
towards this end.
Iodine deficiency is the single most preventable cause of brain damage in children, and it is now well
known that Universal Salt Iodization (USI) is the most cost-effective strategy for eliminating it. In Africa
household consumption of iodized salt increased from 42 per cent in 1995 to 60 per cent by 2008. Six
African countries have made significant improvements in the household use of iodized salt19. While seven
have achieved the Universal Salt Iodization Goal (USI) of 90% household use of iodized salt: Burundi,
Kenya, Lesotho, Nigeria, Tunisia, Uganda and Zimbabwe. Documentation of country experiences20,21,22,23
18
Aguayo VM, Garnier D, Baker SK. Drops of life: Vitamin A Supplementation for Child Survival.
Progress and Lessons Learned in West and Central Africa. UNICEF Regional Office for West and Central Africa, 2007
19 These include Democratic Republic of the Congo, Egypt, Ivory Coast , Madagascar, Mali, and Swaziland.
20 UNICEF ESARO, 2008, ‘Protecting children’s brain development through universal salt iodization: Successes and challenges in Eastern and
Southern Africa’, Nairobi, United Nations Children’s Fund Eastern and Southern Africa Regional Office.
10
shows that the essential requirements of successful salt iodization programs are: (1) high-level
government commitment, reflected in policy, legislation, standards and funding; (2) continuous consumer
education on the dangers of iodine deficiency and the benefits of iodized salt, leading to demand for it; (3)
regular monitoring and enforcement; (4) ‘buy-in’ by salt producers, wholesalers and retailers; and (5) a
national coalition to monitor implementation and enforcement of laws. However, concerted efforts are
still needed to reach annually 13 million African newborns that remain unprotected from the scourges of
iodine deficiency.
Six African countries with significant increases in iodized salt consumption
%
100
around 1995
around 2005
84
80
79
78
75
80
79
60
40
31
28
26
20
1
12
1
0
Madagascar
Egypt
Mali
Congo, Dem.
Rep.
Swaziland
Cote d'Ivoire
Source: UNICEF Global Database
The large scale of micronutrient malnutrition (including iron, folic acid, zinc and vitamin A) throughout
Africa and their consequences for economic development call for immediate and large-scale action. The
most cost-effective strategies to address micronutrient malnutrition are fortifying major food vehicles
(staple food) like wheat or maize flour with iron, folic acid, zinc and other micronutrients, plus sugar and oil
with vitamins A and D. A number of African countries are making progress on food fortification, with some
demonstrating significant impact on improved nutrition and survival. South Africa launched its national
food fortification program in 2003, in partnership with international organizations including Global Alliance
for Improved Nutrition (GAIN), Micronutrient Initiative (MI) and UNICEF. It required any manufacturer of
bread and wheat flour or maize meal to fortify these staples with eight micronutrients including vitamin A,
folic acid, iron and zinc. A 2007 study found a significant decline in birth defects resulting from the
fortification program, with reduction in spina bifida and anecephaly by 41.6 per cent and 10.9 per cent,
respectively. A separate study found a 66 per cent reduction in perinatal deaths related to neural tube
defects (NTDs), and 39 per cent reduction in NTD-related infant mortality.24 In Morocco, a total of 79 mills
are fortifying flour with iron and folic acid. These mills produce 60 percent of the industrial flour consumed
nationwide. While, cooking oil is being fortified with vitamins A and D. Eighty per cent of the oil consumed
in the country is fortified.25 “Fortifying Cooking Oil with Vitamin A across West Africa” is a new partnership
21
J. Egbuta, F. Onyezili and K. Vanormelingen, 2003, ‘Impact evaluation of efforts to eliminate iodine deficiency disorders in Nigeria’, Public Health
Nutrition 6(2):169-173.
22 UNICEF, 2008, ‘Sustainable elimination of iodine deficiency’, New York, United Nations Children’s Fund.
23 Consultation ouest africaine sur l’iodation universelle du sel. Accélérer le progrès vers l’iodation universelle du sel en Afrique de l’ouest - Dakar,
19-21 Octobre 2004
24 MI. 2009. Investing in the future: A united call to action on vitamin and mineral deficiencies. Global Report 2009.
MI/FFI/GAIN/USAID/WB/UNICEF. Ottawa, Ontario, Canada: MI.
25 UNICEF. 2009, presentation prepared for the first African Task Force on Food and Nutrition Development (ATFFND) Meeting, Addis Ababa, 26-27
February 2009.
11
of the eight Francophone countries of West Africa and are members of the Monetary and Economic Union
of West Africa (UEMOA): Benin, Burkina Faso, Côte d'Ivoire, Guinea Bissau, Mali, Niger, Senegal and Togo.
This partnership has led to regional standards making compulsory the fortification of cooking oil with
vitamin A in all the eight countries.26
In line with NEPAD’s Ten Year Strategy, concentrated efforts are needed to launch and support scale-up
elimination of Vitamins and Mineral Deficiencies (VMDs), which has as one of its central focus expansion
and support of food fortification initiatives. The Ten Year Strategy emphasizes multiple approaches
including dietary diversity; hence strong collaboration with the agriculture sector is imperative.
Recent WHO estimates have shown that mortality among children with severe acute malnutrition (SAM) is
5 to 20 times higher compared to well-nourished children.27 There has been encouraging progress made
to treat children with SAM in several African countries through community management of acute
malnutrition (CMAM), a comprehensive system for identifying, referring and treating children with acute
malnutrition. CMAM involves: (1) community-based screening; (2) referral to appropriate care, based on
degree of wasting and presence of complications; (3) specific treatment protocols, food supplements and
medicines; and (4) monitoring and evaluation and supply management. Ethiopia is implementing the
largest program ever – targeting 100,000 new admissions into CMAM per month; Malawi is close to
reaching countrywide coverage with CMAM, aiming to reach 14,000 new admissions per month; Niger has
scaled up integrated management of acute malnutrition, with over 200,000 children treated in 2008. The
link between acute malnutrition and mortality is well established, so effective treatment or prevention of
acute malnutrition is widely expected to have a significant impact on the mortality of young children in
these countries. Particularly in countries with high HIV burden, a large proportion of children (as high as 40
to 60 percent) with severe acute malnutrition are also found to be HIV positive, hence the importance of
testing children for HIV in nutrition rehabilitation units with referral for treatment as well as screening
children for malnutrition in pediatric treatments with referral for appropriate nutrition management and
treatment.28 An estimated 16.4 million children suffer from moderate and severe acute malnutrition in
Africa, as such accelerated progress is needed further strengthen and deepen the ongoing CMAM
programs across the countries and to scale-up.
Governments in several countries of Africa already provide targeted cash transfers, small predictable sums
of money to ultra poor families with children which are a relatively new and successful strategy in the
region to alleviate household poverty. Such grants empower recipients by providing them with greater
freedom of choice in consumption decisions. A number of cash transfer programmes in the region have
been shown to have a large and positive impact on nutritional status, food consumption, dietary diversity,
reduced incidence of illness and demand for health services. In other countries, efforts are under way to
develop national social protection strategies which include social cash transfers.
Such grants give recipients greater freedom of choice in consumption decisions and help reach the most
vulnerable – rural and urban poor and those affected by HIV. A number of cash transfer programmes in
Africa (Ghana, Malawi, Sierra Leone, South Africa and Zambia) have demonstrated a large and positive
impact on nutritional status, food consumption, dietary diversity, reduced incidence of illness and demand
for health services.29 Ghana’s Livelihood Empowerment Against Poverty (LEAP) program and Nigeria’s In
Care of the Poor (COPE) are setting the tone for social protection systems in West Africa.30
26
http://www.hki.org/about/press_releases/West%20Africa%20Millers%20Commit.html
WHO, 2007, ‘Community-based management of severe acute malnutrition: A joint statement of the World Health Organisation, World Food
Programme, United Nation System Standing Committee on Nutrition and United Nations Children’s Fund’, Geneva, World Health Organisation
28 UNICEF ESARO. 2008. ‘Nutritional care of HIV-positive children in Kenya, Malawi and Zambia: A progress review,’ Nairobi, United Nations
Children’s Fund Eastern and Southern Africa Regional Office.
29 UNICEF, 2007, ‘The impact of social cash transfers on children affected by HIV and AIDS: Evidence from Zambia, Malawi and South Africa’, New
York, United Nations Children’s Fund.
30 R. Holmes and N. Jones (2009) ‘Child-sensitive Social Protection in West and Central Africa: Opportunities and Challenges’
27
12
Overall Food and Nutrition Security Programme Success Factors31







31
High-level political commitment and partnership: Nutrition and food security is multi-sectoral in
nature and often falls within the mandate of several Ministries - including Health, Agriculture,
Education, Industry, and Social Welfare, so programmes need clear roles and responsibilities and
effective coordination. High-level government leadership, commitment and ownership is key to
success, requiring clarity and well-coordinated support from all the concerned sectors and
international community. The Renewed Efforts Against Childhood Hunger and Under-nutrition
(REACH) initiative provides a good example of inter-sectoral and inter-agency collaboration and
partnership to improve nutrition. REACH aims to accelerate progress towards MDG-1 targets and
although established by FAO, WHO, UNICEF and WFP in 2008, the centre of the strategy is to support
Governments in the achievements of nutrition outcomes through a solid coordination of efforts at
country, regionally and globally, through multi-donor funding in support of country-led plans.
Linkages with all the key sectors: The integrated core package of nutrition interventions described in
this paper need to be implemented in conjunction with relevant sectors as health, Industry, Finance
and Agriculture, to ensure a holistic approach to improved household food security.
Situation analysis: This should be the starting point of a comprehensive nutrition programme design,
multi-sectoral in approach, with the appropriate links to all the key sectors so as to address the various
immediate, underlying and basic causes of malnutrition including household food security, poverty,
and inequity issues, for its effective and sustainable elimination. This analysis should form as basis for
appropriate national policies, adequate legislative frameworks and strategies that ensure the best use
of local resources. While, global, continental or regional policy guidance and technical documentation
already established can facilitate countries’ policy design and choice of implementation strategy,
standards to enhance regional harmonization and integration.
Capacity-building: Capacity building is critical for of nutrition programmes. The reach and coverage of
the health system needs to be reviewed, opportunities identified, and knowledge and skills updated on
the core integrated nutrition interventions to improve nutrition so that health and other extension
workers at all the key levels – facility, community can deliver these services effectively.
Communication and community: Effective large-scale communication campaigns and community
involvement are key conditions for programmes that seek to improve child care and promote
behavioural change. Regular support and counselling of caregivers at the community level in a
comprehensive manner, with messaging on feeding, care and hygiene, and disease prevention and
treatment can lead to positive outcome. Communities should not be seen as passive recipients of
services but as active agents for identifying and addressing gaps, assuming responsibilities and ensuring
adequate nutrition is provided for all. Many countries successfully rely on community-based health
workers or volunteers who operate closely with official health and other social service providers.
Corporate and social responsibility: The involvement of the private sector can ensure availability of
appropriate and affordable products, such as micronutrient fortified foods (e.g. iodized salt, fortified
wheat or maize flour, cooking oil or sugar), high quality foods for complementary feeding and
supplementary foods, and micronutrient supplements. This is an important strategy that can improve
access to quality foods and supplements, to eliminate micronutrient malnutrition and promote good
nutrition and health. The private sector, with its wide access to populations, also can play an important
role in encouraging behaviour change to promote good nutrition and healthy lifestyle; thereby
enhance corporate social responsibility and help improve maternal and child nutrition. It is critical that
companies comply with the International Code of Marketing of Breastmilk Substitutes and all relevant
food safety standards.
Resources: Nutrition programmes are severely under-resourced – despite evidence of their
effectiveness, as demonstrated by the Copenhagen Consensus results. The costs of programmes
would vary widely between countries depending on varying local conditions, but available estimated
cost figures from other countries and internationally can help provide an indication on the level of
resources required. The REACH initiative is estimated to require US$36 per child per year to
Adopted from UNICEF 2009 (ibid).
13
implement an integrated programme with cost-effective interventions. The programme “A Good Start
in Life” in Peru documented a significant reduction in stunting at an annual cost of about US$117 per
child.
4. The Proposed Actions:
Three strategic areas are proposed, where accelerated implementation of key priority actions are urgently
needed, to address the high levels of stunting in Africa, while building on successes seen as well as drawing
from lessons learned across Africa to reduce prevalence of underweight, micronutrients deficiencies, and
to manage severe acute malnutrition. These include:
(1) Prioritize sustainable access to evidence-based essential integrated maternal and child
nutrition interventions32 to reduce stunting, and enhance maternal and child survival - through
a multi-sectoral approach.
Health;
The health sector plays an extremely important role in enhancing food and nutrition security both through
helping to prevent and treat debilitating illnesses as well as nutritional deficiencies among populations and
because of the critical role that health staff plays in promoting good nutritional, health and hygiene
practices. Regarding the nutritional aspects of health services, it is usually the health workers who
provides the most influential advice to the families on infant and child feeding, nutrition during pregnancy
and disease and in other situations and it is also through the health workers that families/individual can be
provided with supplementation of micronutrients when needed, as well as promote consumption of
diversified and fortified foods. If properly trained and supported, health workers – at both facility and
community levels - are best placed to identify early signs and treatment of malnutrition.
Water and sanitation;
Water is an essential element for virtually all aspects of human life needed both for direct consumption,
for cooking and cleaning and hygiene. Access to safe water and sanitation, as well environmental health
and hygiene is a crucial measure of preventing infectious illnesses - such as diarrhea, which is closely
related to under-nutrition and is one of the main child killers. Furthermore, it is a key element in
agriculture production, hence food security and nutrition. Poor rainfall reliability is often seen as the main
constraints to increased food production in many parts of Africa. In agriculture and rural development it is,
therefore, essential to establish close collaboration with water resource management departments to
address the specific constraints and opportunities in the locations under consideration.
Industry and trade;
Since most people buy rather than produce the food they eat, income and income-generating activities are
essential for food security and this relates to the first area above. Industry can also provide critical support
for nutritional programmes through fortification and marketing of key staple foods with micronutrients like
vitamin A, iodine, iron, folic acid, zinc or through producing and marketing of fortified complimentary
foods, and multiple micronutrient powders, as well as producing special therapeutic foods such as Ready
to Use Therapeutic Foods (RUTF) for children with severe acute malnutrition.
Agriculture;
The agriculture sector is very central in ensuring national and household food security. The newly
transformed NEPAD Planning and Coordinating Agency offers a unique opportunity to reaffirm continental
and international commitments, mobilize resources and rededicate Africa to improving nutrition, reducing
the burden of hunger and disease and protecting precious human capital. NEPAD’s Pan African Nutrition
Initiative nested within the Comprehensive African Agriculture Development Programme (CAADP) offers a
promising approach for capitalizing on the natural synergy of increased food production and improved
32
See Annex 1 for more details on the evidence-based essential nutrition interventions.
14
nutrition. African leaders have all commitment themselves to CAADP and already many countries have
adopted CAADP as the framework for agriculture’s renewal and engine for economic growth and are
implementing it. CAADP is meant to catalyze a multi-sectoral process of investment planning, facilitating
capacity building and mobilizing resources to address the burden of malnutrition.
Education;
Education is often regarded as the most important development activity in any country. In most places,
the education sector also has the most extensive coverage and presence in local communities in rural
areas through the schools and the teachers. Basic knowledge on food, health and nutrition is normally
taught as part of the curriculum in all schools but it is generally more uncommon to see a close linkage
between the schools and other efforts to accelerate agriculture and rural development and food and
nutrition security. In the instances where this has been done, however, very good overall achievements
have been recorded through, e.g. school feeding programmes, school gardens to promote vegetables,
fruits and trees, enrolling teachers in ‘functional literacy’, using school children to convey ‘messages’
through songs, drama and poems, etc. If agriculture and rural economies are to be improved in Africa it
seems imperative that the schools have to be part of the transformation in a very systematic way. In this
regard, the NEPAD Home Grown School Feeding (HGSF) flagship programme provides the best opportunity
for an integrated approach to feed school children with healthy meals while stimulating production and
improving market access for small holder farmers. A number of countries including Ghana, Cote d’Ivoire,
Nigeria, have launched the HGSF.
Actions:
1. Review, update and adopt comprehensive national nutrition policies to establish plans to meet
national targets with priority attention on stunting reduction.
2. Ensure the economic and social benefits of nutrition security are reflected and supported in other
sectors including agriculture, water resources, industry and education.
3. Contribute support to strengthen nutrition capacity at all the key levels: advocate for and support
increased public sector budget for nutrition, aiming for at least 2% in each of the key sectors –
agriculture, health, water resources, industry and education, and build human resource capacity in
nutrition across the key government sectors – agriculture, health, education, social welfare – and
ensure that one responsible person/champion/institution is assigned as responsible for the
nation’s nutrition.
4. Provide focused assistance on a preventive approach covering the window of opportunity including
all under twos and pregnant and lactating women through a solid Mother and Child Health
Nutrition activity to fight chronic malnutrition and micronutrient deficiencies.
5. Ensure that assistance through a curative approach to manage moderate and severe acute
malnutrition (via therapeutic and supplementary feeding) is at the centre of any nutrition support
that covers the most vulnerable people in the selected areas, which have fallen below accepted
nutritional thresholds (emergency assistance).
6. Support national communication campaign to promote good nutrition and healthy life style
especially during the early period of life between - 9 to 24 months, as the most vulnerable period
to nutritional deprivation - to promote consumption of diversified diets (variety of high nutrient
dense vegetables, fruits, indigenous crops, and animal source foods), micronutrients supplements
or fortified foods before and during pregnancy, optimal infant feeding (early breastfeeding
initiation, EXBF for 6 months etc.) and complementary feeding, as well as access to health care and
hygiene practices, based on evidence.
7. Ensure that the health workers in rural areas establish a close collaboration with agriculture
extension staff and the local schools to provide well coordinated nutrition services and support to
their communities, including promotion of and counseling on optimal feeding, care and nutrition
during the most vulnerable period to nutritional deprivation (-9 to 24 months) as well as in
identification and management of acute malnutrition.
15
(2) Launch AU/NEPAD TYS to eliminate Vitamins Minerals Deficiencies (VMDs) as one of the
most cost-effective strategy to improve nutrition, health and survival.
Actions:
1. Support to sustain significant achievements seen across Africa to double twice yearly VAS to children 659 months, integrated with other high impact interventions through its institutionalization.
2. Support national fortification policy formulation and adoption of national standards, in harmony with
global guidelines and standards, for mandatory fortification of key staple foods.
3. To support Governments in the sustainable and local production of nutritious food for complementary
feeding, including fortification of key staple foods as per national standards.
4. Support to sustain achievements made to date towards Universal Salt Iodization (USI) goal, and
accelerate progress in countries making efforts to reach the USI goal by addressing the remaining main
bottlenecks.
5. Establish a well coordinated approach with the key public and private sectors to assure quality food
fortification, and marketing as per national standards, to promote good nutrition and healthy lifestyle,
consumption of diversified diet, fortified foods, use of soap for hand washing, hygiene and safe food
preparation practices, particularly among women before and during pregnancy, and children 6-24
months of age to enhance maternal health and survival, as well as child growth, development, and
survival.
(3) Advocate for and support effective management of moderate and severe acute malnutrition
in both emergency and non-emergency settings
Africa continues to be affected by humanitarian situations emerging from natural calamities as well as civil
strife. The effects of such crisis on children in particular is often devastating and deadly, often manifesting
into the most severe forms of hunger, starvation and acute malnutrition. The technical means for treating
children with severe acute malnutrition is now quite advanced but the problem remains that help is usually
only coming when the situation has deteriorated very badly and many children and adults are in lifethreatening conditions or have already perished. These situations may actually increase rather than
decrease in the future as the global climate crisis is expected to lead to more frequent droughts and floods
on the continent.
The national and regional capacity for ‘early warning’ and for emergency preparedness and response need
to be scaled up to prevent humanitarian emergencies rather than waiting for a (predicable) disaster to
happen. International agencies like WFP, UNICEF, FAO and WHO, together with other partners, should be
tasked to build regional and local capacity to strengthen early warning and nutrition surveillance systems,
handle emergency food supplies, organize therapeutic feeding, control epidemics, etc.
Mechanisms need to be put in place to allow countries to both address crisis situations when they occur
while still maintaining a steady path to long-term institutional capacity building towards sustainable
achievement of development goals, including targeted nutrition support to the most vulnerable population
groups (e.g. the ultra poor, HIV affected or infected) to prevent and manage moderate and severe acute
malnutrition, i.e. in non-emergency settings.
Actions:
1. Strengthen national capacity to effectively identify and respond to problems of moderate and
severe acute malnutrition in all countries using facility and community-based approaches, with the
aim to expand and sustain/institutionalize the programme.
2. Provide support to collaboration with public and private sectors on production of foods for special
needs (e.g. RUSF and RUTF for management of moderate and severe acute malnutrition as a
critical measures to prevent further progression from MAM to SAM and for life-saving).
16
3. Advocate and support for countries to strengthen national nutrition information and surveillance
systems with links to early warning, to up-date their emergency preparedness and response plans
with support from humanitarian partners.
ANNEX 1: Evidence-based Interventions to Improve Nutrition:
In January 2008 The Lancet – issued a special five-part series on nutrition; demonstrating the availability of
proven interventions that could address longstanding maternal and child nutrition problems and save
millions of lives33. The Lancet set of interventions focused on the period in the life cycle from the mother’s
pregnancy to the child’s second birthday, which provides a critical “window of opportunity” in which
interventions to improve maternal and child under-nutrition can have a positive impact on young children’s
prospects for survival, growth and development, especially in countries with a high burden of undernutrition.
A core package of effective nutrition interventions, as per UNICEF global recommendations (2009) and
agreed upon by experts and program partners are highlighted in the table below. Successful scale-up
implementation of these programmes will lead to enhancing significantly maternal and child survival and
development in the short-run and in the long-run to contribute positively to communities and national
economic growth and development through improved health and nutrition – which would lead to reduced
health expenditures, and improved economic productivity later in life.
Priority Interventions for the prevention of under-nutrition and management of acute
malnutrition by stage of life cycle
Interventions
Justification
Commodities
needed
Delivery Mechanisms
Indicators
-Facilitate support for
private sector to access
quality
MNS
fortificants,
facilitate
support
local
production of quality
fortified foods and
appropriate marketing
(as
per
national
standards)
-Public-Private
sector
collaboration (development of
national fortification policy,
legislation and standards,
support capacity building,
quality
assurance
and
enforcement
of
national
regulations, monitoring)
-Intervention
at
home/community
level
(increase
awareness
on
benefits of good nutrition;
promote use of and create
demand
for
adequately
fortified foods)
-household consumption of
iodized salt
-National food fortification
policy,
legislation
for
mandatory fortification of
wheat/maize flour, cooking
oil/sugar, standards and
enforcement mechanisms in
place
-Prevalence
of
iodine
deficiency
-Prevalence of iron deficiency
anemia
-Intervention
at
home/community
level
(increase
awareness
on
benefits of good maternal
nutrition and IYCF; promote
intake of IFA, de-worming,
iodized salt, and other fortified
foods; enable women to gain
access to ANC and maternal
nutrition/IYCF services; public
information
and
communication campaign on
maternal
nutrition/IYCF;
education and counseling to
enhance IFA compliance and
uptake, create demand of
-use of IFA supplements
-Household consumption of
adequately iodized salt
Adolescent/Pre-pregnancy
Food fortification with
folic acid, iron, vitamin
A, zinc and iodine
Reduces micronutrient
deficiencies; prevents
neural tube defects and
negative
effects
associated with iodine
deficiency in early
pregnancy
-Counseling Aids and
IEC materials
Pregnancy
-Iron folic acid (IFA) and
de-worming
-Reduces
iron
deficiency and other
micronutrient
deficiencies; pregnancy
complications;
maternal mortality and
low birth weight
-Promote use of locally
available
foods to
ensure increased intake
of important nutrients
-Reduces wasting and
micronutrient
deficiencies;
contributes to reducing
low birth weight
-Promote use of iodized
salt, and other fortified
-Improves
foetal
development, cognition
33
-Iron
folic
supplements
acid
-de-worming tablets
-Counseling Aids and
IEC materials
The Lancet, “Maternal and Under-nutrition,” Special Series, January, 2008.
17
foods (with iron, folic
acid, zinc, Vitamin A)
and intelligence in
infant; reduces risks of
complication
during
pregnancy and delivery;
prevents
goiter,
miscarriages, stillbirth
and cretinism
-Fortified
food
supplements (e.g. cornsoya blends, lipid-based
nutrient supplements)
for
undernourished
women
-reduces wasting and
micronutrient
deficiencies,
contributes to reducing
low birth weight
-Facilitate support for
private sector to access
quality
MNS
fortificants,
facilitate
support
local
production of quality
supplementary foods
and
appropriate
marketing
(as
per
national standards)
-Lab tests (Anemia)
Birth
 Intervention to
the Infant
-Skin to skin contact
with the mother for at
least one hour
-Initiation
of
breastfeeding within 1
hour
(including
colostrum feeding)
Less than 6 months
 Intervention to
the mother
-micronutrient
supplementation
-Improved use of locally
available
foods,
fortified
foods
&
Supplementary foods
of
undernourished
women

Intervention
the Infant
-Exclusive
breastfeeding
-Contributes
to
reduction of neonatal
deaths
-Reduces iron & other
micronutrient
deficiencies & improve
quality of breastmilk
-Prevents
maternal
under-nutrition; helps
maintain ability to
breastfeed & assure
high quality breastmilk
-MNS supplements
-Assure
optimal
nutrient intake and
prevents
childhood
diseases and death
-Contributes
to
reducing
mother-tochild transmission of
HIV and to reducing
infant mortality
-Counseling Aids and
IEC materials
-As per above – links
with private sector to
support
local
production of fortified
and
supplementary
foods
to
-Appropriate feeding of
HIV-exposed infants
iodized salt and other fortified
foods, and optimal IYCF)
-First-level health facilities
and outreach (provision of and
counseling
on
maternal
nutrition and IYCF – with links
or integration with ANC,
screening for anemia and
acute malnutrition)
-Intervention
at
referral
facilities (treatment of severe
anemia,
and
acute
malnutrition)
-Public-Private
sector
collaboration (as per above to
facilitate adequate fortification
of foods with MNS)
-First-level maternity health
facilities
and
outreach
(provision of counseling on
IYCF, provide support on
lactation management as per
national IYCF/BFHI policy)
-Intervention
at
home/community
level
(increase
awareness
on
benefits optimal IYCF (early BF
initiation) and on ten BFHI
steps
to
successful
breastfeeding; enable women
to gain access to maternal
health delivery services.
-Prevalence
of
early
breastfeeding
initiation
(within the first hour)
-Proportion of infants not
weighed at birth
-Intervention
at
home/community/
work
place level (promote safe and
nutritive diet; intake of MNS,
fortified
foods;
promote,
support protect EXBF as per
national IYCF/BFHI policy;
optimal pregnancy spacing)
-First-level health facilities
and
outreach
(promote,
support protect EXBF – as per
national BFHI/IYCF policy,
screening for maternal acute
malnutrition – with links to or
integration with post-natal
clinic services)
-Intervention
at
referral
facilities (management of
maternal acute malnutrition)
-Public-Private
sector
collaboration (as per above to
facilitate local production of
fortified,
supplementary
foods)
-Intervention
at
home/community/
work
place level (promote, support
protect EXBF as per national
policy)
-First-level health facilities
and
outreach
(promote,
support protect EXBF as per
national policy – with links to
or integration with post-natal
clinic services; including in
context of HIV with links to
-International
code
for
breastmilk
substitutes
enacted, & enforcement
mechanisms in place
-Maternity protection in
accordance
with
ILO
convention 183 enacted
-Exclusive breastfeeding rate
(<6 months)
18
PMTCT
&
diagnosis)
early
infant
6 to 24 months

Intervention to
the mother
-Improved use of locally
available
foods,
fortified
foods
&
Supplementary foods
of
undernourished
women
-hand washing with
soap
-Helps
maintain
breastfeeding
and
ensure
high-quality
breastmilk as well as
prevent
maternal
under-nutrition
-Counseling Aids and
IEC materials
-Helps reduce diarrhea
& associated undernutrition in the child
-As per above – links
with private sector to
support
local
production of fortified
and
supplementary
foods + promotion use
of soaps for hand
washing, with links to
the water sector
Prevents
and
decreases underweight,
stunting, wasting and
micronutrient
deficiency
and
contributes to survival
and development
-Provides
significant
sources of nutrients;
protects
from
infections
-Contributes
to
reducing
mother-tochild transmission of
HIV and reduces child
mortality
-Reduces duration and
severity of diarrhea &
subsequent episodes;
reduces mortality
-Contributes
to
reducing
anemia;
Vitamin A deficiency &
under-nutrition: reduce
child mortality
-Improves brain &
physical development;
prevents motor and
hearing
defects,
prevents goiter
-Contributes
to
reducing child mortality
-Counseling Aids and
IEC materials

Intervention to
the Infant
-Timely, adequate, safe
&
appropriate
complementary feeding
(including
improved
use of local foods,
MNS,
lipid
based
nutrient supplements &
fortified
complementary foods)
-Continued
breastfeeding
-Appropriate feeding of
HIV-exposed infants
-Zinc treatment
diarrhea
for
-VAS & de-worming
-Iodized salt consumed
as table salt and/or as
food grade salt (used in
food processing)
-Management
severe
malnutrition
-Management
moderate
malnutrition
-Hand
soap
washing
of
acute
of
acute
with
-Prevents progression
to SAM and contributes
to reduction of child
mortality
-Helps reduce diarrhea
& associated undernutrition
-Zinc supplements with
new ORS
-VAS capsules and deworming tables
-As per above – links
with private sector to
support
local
production of fortified
complementary foods,
lipid-based
nutrient
supplements,
RUTF,
RUSF + promotion use
of soaps for hand
washing, with links to
the water sector
-Intervention
at
home/community/
work
place level (promote safe and
nutritive diet; intake of
fortified
foods;
promote,
support protect continued BF
as per national IYCF/BFHI
policy; hand washing with
soap, hygiene safe food
preparation practices)
-First-level health facilities
and
outreach
(promote,
support protect continued BF –
as per national BFHI/IYCF
policy, screening for maternal
acute malnutrition – with links
to or integration with postnatal clinic services)
-Intervention
at
referral
facilities (management of
maternal acute malnutrition)
-Public-Private
sector
collaboration (as per above to
facilitate local production of
fortified, supplementary foods
+ promotion of use of soap for
hand washing – with links to
water sector)
-Intervention
at
home/community/
work
place level (promote timely,
safe
and
appropriate
complementary foods; fortified
complementary foods & lipidbased nutrient supplements;
promote, support protect
continued BF as per national
IYCF/BFHI policy; promote VAS
+
de-worming,
early
identification
and
management of MAM/SAM
w/o complications;
hand
washing with soap)
-First-level health facilities
and outreach (promote timely,
safe
and
appropriate
complementary foods; fortified
complementary foods & lipidbased nutrient supplements;
promote, support protect
continued BF as per national
IYCF/BFHI policy – with links to
or integration with post-natal
clinic services; including in HIV
context with links to PMTCT,
EID; provide zinc in mgmt of
diarrhea; provide VAS + deworming – with links to CHDs,
screen for moderate and acute
malnutrition)
-Intervention
at
referral
facilities (management severe
acute
malnutrition
with
complications)
-Public-Private
sector
collaboration (as per above to
facilitate local production of
fortified,
complementary
foods + promotion of use of
-International
code
for
breastmilk
substitutes
enacted, & enforcement
mechanisms in place
-Maternity protection in
accordance
with
ILO
convention 183 enacted
-Timely
introduction
of
complementary foods (with
continued breastfeeding)
-Continued breastfeeding at
two years
-Full coverage of VAS
-National guidelines for
management of severe acute
malnutrition incorporating
community-based approach
-Policy on new ORS formula
and zinc for management of
diarrhea
-Policy
on
community
treatment of pneumonia
with antibiotics
19
soap for hand washing – with
links to water sector)
24-59 months

Intervention
to the Infant
-VAS & de-worming
-MNS
powder
fortified
foods
children
or
for
-Iodized salt consumed
as table salt and/or as
food grade salt (used in
food processing)
-Management
severe
malnutrition
-Management
moderate
malnutrition
-Hand
soap
washing
of
acute
of
acute
with
-Contributes
to
reducing
anemia;
Vitamin A deficiency &
under-nutrition: reduce
child mortality
-Reduces iron & zinc
deficiency
-Improves brain &
physical development;
prevents motor and
hearing
defects,
prevents goiter
-Contributes
to
reducing child mortality
-Prevents progression
to SAM and contributes
to reduction of child
mortality
-Helps reduce diarrhea
& associated undernutrition
-Counseling Aids and
IEC materials
-VAS capsules and deworming tables
-As per above – links
with private sector to
support
local
production of fortified
foods for children /
MNS powder, RUTF,
RUSF + promotion use
of soaps for hand
washing, with links to
the water sector
-Intervention
at
home/community/
work
place level (promote VAS + deworming, fortified foods for
children; MNS powder; early
identification
and
management of MAM/SAM
w/o complications;
hand
washing with soap)
-First-level health facilities
and outreach (provide VAS +
de-worming – with links to
CHDs, promote nutritive diet &
fortified foods for children;
screen for moderate and acute
malnutrition)
-Intervention
at
referral
facilities (management severe
acute
malnutrition
with
complications)
-Public-Private
sector
collaboration (as per above to
facilitate local production of
fortified foods for children +
promotion of use of soap for
hand washing – with links to
water sector)
-Full coverage of VAS
-National guidelines for
management of severe acute
malnutrition incorporating
community-based approach
20