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Accelerating nutrition improvements in Sub-Saharan Africa: strengthening nutrition surveillance: final report 2012-2016

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ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA STRENGTHENING NUTRITION SURVEILLANCE FINAL REPORT 2012-2016

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA STRENGTHENING NUTRITION SURVEILLANCE FINAL REPORT 2012-2016 (WHO Award 59469; GAC PO 7058545) Project Budget: CAN$ 10 200 000 Project duration: 29 March 2012 – 30 September 2016 Submitted by: Dr Francesco Branca Director of Nutrition for Health and Development World Health Organization

WHO/NMH/NHD/17.5

© World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.. Suggested citation. WHO. National Implementation of the Baby-friendly Hospital Initiative, 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who. int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who. int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Alberto March Cover photo credit: Rachel Palmer/Save the Children Printed in Switzerland

Acknowledgments his report has been prepared under the leadership of Francesco Branca, Director of the WHO Department of Nutrition for Health and Development (WHO/NHD), in close collaboration with staff from WHO headquarters (Monika Blössner, Kaia Engesveen, Chizuru Nishida and Katerina Ainali), the Regional Office for Africa (Adelheid Onyango) and intercountry support teams (Hana Bekele and Elisa Dominguez). Thanks to Cathy Wolfheim for editing and coordinating the production of the document. WHO is grateful to Global Affairs Canada for the generous financial support provided to the Accelerating Nutrition Improvements project.

Table of Contents Acknowledgements Part I : Overview Background Objectives Expected deliverables Grant coordination and supervision Reporting plan Communications ANI Project Map Part II: Global and regional activities Part III: Country activities Overall achievements in countries Detailed implementation status in countries Burkina Faso Ethiopia Mali Mozambique Rwanda Senegal Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe Part IV: Management Financial Report v 1 1 2 2 2 2 3 3 5 6 8 10 10 12 13 15 17 21 23 26 28 30 33 35

VII

Part I: Overview

[A] Background

ccelerating Nutrition Improvements in sub-Saharan Africa (ANI) was implemented in 11 countries (Burkina Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe), in collaboration between the ministry of health (MoH), the World Health Organization (WHO) and local partners. ANI was supported by Global Affairs Canada. Activities to improve nutrition surveillance in the 11 countries are presented in this report. Three countries, Ethiopia, Uganda, and the United Republic of Tanzania received additional support for scaling up nutrition interventions; those activities are presented in a separate document. Surveillance activities were implemented through country-led programmes and strategies and within existing systems to avoid duplication and ensure sustainability. ANI was also a platform for WHO’s engagement with United Nations Renewed Efforts Against Child Hunger (REACH) and with the SUN Secretariat.

[B] Objectives

The surveillance component of the ANI project aims to: strengthen nutrition surveillance systems in eleven high-burden countries; conduct nutrition surveys in four countries; provide support to countries through global and regional-level activities.

[C] Expected deliverables

improved baseline data in four countries;

strengthened surveillance systems in 11 countries, leading to improved-decision making and ability to measure progress; a nutrition profile for eleven countries;

a global monitoring framework for nutrition.

[D] Grant coordination and supervision

The grant is managed jointly by the Director of Nutrition for Health and Development (NHD) in WHO headquarters, the Director of the Family and Reproductive Health Cluster in the WHO Regional Office for Africa and WHO Country Offices in respective ANI countries. The project is coordinated through routine technical interaction at the three levels of WHO: headquarters, region, and country. The Regional Office for Africa is based in Brazzaville and has three intercountry support teams. One nutrition officer based in Harare provides technical support and oversight for the seven ANI countries in Eastern and Southern Africa and another based in Ouagadougou supports the four West African countries. The Regional Adviser for nutrition in the WHO Regional Office for Africa contributes to country technical support and oversees administration of the grant. The original end date of the grant, 30 June 2015, was extended to 30 September 2016. The present report describes activities carried out in 2016, building on the 2015 progress report, and is being prepared in parallel with the final narrative report. The final report will summarize major inputs, activities, outputs and results

[E] Reporting plan

of the project, as well as lessons learned, according to the agreed Performance Monitoring Framework.

[F] Communication

The ANI project involves more than 25 people in WHO country offices, inter-country support teams, the Regional Office for Africa, and headquarters. Standard operating procedures were developed to ensure and facilitate coordination, communication, and complementarity of all offices concerned. Monthly coordination teleconferences have been carried out with the involvement of WHO staff at all levels, and routine communication is carried out as needed.

ANI Project Map

2 4 1 Surveillance

1 Burkina Faso 2 4 Mali

2 2 1 3

3 Mozambique Senegal

Surveillance + scale up

1 Ethiopia 2 3 Uganda United Republic of Tanzania

3 4

Surveillance + surveys

1 2 3 4

Rwanda Sierra Leone Zambia Zimbabwe

WHO /Pierre Albouy

Part II: Global and regional activities The agreement with Global Affairs Canada envisaged the production of an Africa regional nutrition report showing the data collected throughout the project period and reflecting the progress towards achieving the six Global Nutrition Targets for 2025. The report, which will be submitted with the final ANI Project report, shows the status of the WHO African Region with respect to the six global targets as well as the intermediate outcomes, process and policy environment indicators that highlight where action is needed to drive progress. The report reviews potential data sources for nutrition surveillance and describes the contribution of the ANI project to analysing existing health information systems and their potential to integrate nutrition indicators. Although the ANIsupported countries introduced nutrition indicators into existing systems, the data flow is not well enough developed for routine data to be used for monitoring. A review of various survey methods used suggested an intermediate approach between periodic surveys and routine data that could serve to provide population nutrition updates. This would enable countries to report progress on the global nutrition targets. The rSIS (real-time Strategic Information System) is a regional health observatory developed by WHO and established in the Regional Office for Africa. A nutrition module allowing the capture of nutrition data from countries was developed and is being set up within the system to facilitate nutrition surveillance at regional level. Once finalized, procedures for extracting and exporting nutrition data from health management information systems (HMIS) and integrated disease surveillance and response (IDSR) systems at country level will be developed. The procedures will include data quality control, and detailed analysis linking intermediate health outcomes and process indicators to the selected nutrition indicators. The operational guidance to collect data for the Global Nutrition Monitoring Framework was finalized, which will facilitate the development of country information systems. Additional global activities were sustained with funds from sources other than the ANI project. This being the end of the project period, greatest attention was paid to supporting, completing and planning the future of country activities.

Part III: Country activities Building on previous OVERALL ACHIEVEMENTS work, activities in 2016 • STRENGTHENING THE QUALITY OF NUTRITION DATA: The standard questionnaire for Service Availability and Readiness focused on consolidating Assessment (SARA) surveys to evaluate quality of care was revised to include several nutrition indicators. The process will now allow country-owned systems evaluating the presence of anthropometric equipment in health and developing facilities and the quality of anthropometric measurements for wasting, stunting and overweight at primary health centres. initiatives to improve The questionnaire was adapted and validated for Burkina Faso, regional-level support and may serve as a basis for other countries implementing SARA surveys in the future. to countries for tracking nutrition targets. • CAPACITY BUILDING: In 2016, a total of 2689 health workers and community health workers, of whom 1563 are women, were trained in anthropometric methods in Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, the United Republic of Tanzania and Zambia. Supervisory visits were carried out in seven countries to maintain the skills of trained workers.

•

NUTRITION DATA ACCESS THROUGH NATIONAL HEALTH INFORMATION SYSTEMS: All 11 countries were able to extract nutrition data from their strengthened health information systems (HMIS and IDSR) and disseminate them through their annual health/nutrition statistics bulletin. In Burkina Faso, the annual surveys based on the SMART (Standardized Monitoring and Assessment of Relief and Transitions) methodology now include the prevalence of overweight/obesity in children under 5 years of age. In Senegal, two rounds of sentinel surveillance provided data on the prevalence of wasting, stunting, obesity, exclusive breastfeeding and anaemia as well as selected determinants of malnutrition.

Courtesy of Manuel Viola Figueras

•

USE OF NUTRITION DATA FOR POLICY DEVELOPMENT: In Burkina Faso, Ethiopia, Rwanda, Senegal, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe, data supported the revision of nutrition policies, the development of strategic nutrition action plans and the definition of national nutrition targets. END-LINE PERCEPTION SURVEYS: Between June and September 2016, end-line perception surveys captured the perceptions of different target groups on nutrition and assessed how these perceptions have evolved along the duration of the project. FINAL EVALUATION: Final evaluations done in Burkina Faso, Ethiopia, Mali, Sierra Leone, Senegal, Uganda and the United Republic of Tanzania identified lessons learnt and challenges, and served to develop a road map for the next phase. Road maps were then used to develop concept papers for fund raising, in view of continued support to strengthening and scaling up systems, to working on the data quality and reliability and to improving data analysis. Countries that participate in the SUN movement have also expressed their willingness to develop national multisectoral information platforms on nutrition.

•

Carlos Olmo/Vagamundos.com

Detailed implementation status by country Burkina Faso Coverage of surveillance activities Number of districts covered 14/30 Number of women 1 756 000 age 15-49 Number of children under 5 878 000

Nord Sahel Est

PROGRESS IN CIP IMPLEMENTATION VALIDATION AND OFFICIAL INTEGRATION OF NUTRITION INDICATORS WITHIN THE NATIONAL HEALTH MANAGEMENT INFORMATION SYSTEM * Although actual coverage is limited to the three regions supported by ANI, from January 2016, HMIS tools and related DHIS2 include nutrition indicators at national level. A national workshop in February 2016 led to the incorporation of nutrition indicators into HMIS tools and a reconfiguration of the District Health Information Systems 2 (DHIS 2)/Entrepôt de données du Burkina Faso (ENDOS-BF) platform. JOINT SUPERVISION In May 2016, pilot health centres in three regions were visited to assess the collection of nutrition data, the use of tools with integrated nutrition indicators and the use of rapidSMS for weekly data transmission. Technical issues at server level were identified and solved, allowing analysis of preliminary data, and a recommendation was made to extend the pilot phase.

EVALUATION OF THE NATIONAL PLAN Carried out in May 2016, this evaluation helped to identify strengths and weaknesses of the national surveillance system. Nutrition data were available and had been included in the 2015 annual bulletin. Further training on anthropometry was recommended as well as the distribution of anthropometry reference tables. The development of a mobile application to provide individual nutrition status based on anthropometric measurements was also discussed. A road map for scaling up activities at country level was developed and is being used to leverage resources for follow-up phases. TECHNICAL AND FINANCIAL SUPPORT WAS PROVIDED FOR THE ANNUAL SMART SURVEY OF 2016 A CONCEPT NOTE FOR A PHASE 2 OF THE ANI PROJECT To continue strengthening the national surveillance system, a concept note is under development, as of September 2016. Another concept note was developed and submitted to the UN network for SUN in Burkina Faso, and is being used by UN agencies to mobilize resources for the roadmap towards national scaling up of surveillance activities. THE “TRACKING TOOL” FOR THE GLOBAL NUTRITION TARGETS This tool was introduced and demonstrated in a training session for staff from the Nutrition Directorate of the MoH, REACH and the consultant in charge of developing Burkina Faso’s multisectoral strategic plan on nutrition. Stakeholders then used the tool to identify and articulate national nutrition targets for the strategic action plan currently under development. This plan is expected to be validated in March 2017.

Women kneading millet to prepare food, Kaya, Burkina Faso. Courtesy of creativecommons.org

Ethiopia Coverage of surveillance activities Number of districts covered 10 /700 Number of women 344 103 age 15-49 Number of children under 5 183 733

Accelerated nutrition improvement (ANI) Intervention area in Ethiopia ANI Intervention woreda ANI Intervention zone

PROGRESS IN CIP IMPLEMENTATION REFRESHER TRAINING AND MENTORING ON THE QUALITY AND USE OF HMIS DATA These were carried out in the ten project districts in three regions (Southern Nations Nationalities and Peoples Republic (SNNPR), Oromia and Amhara). A total of 895 health workers, of whom 483 are women, benefited from this training. Anthropometric equipment to support the collection of surveillance data was procured (380 length/height measures and 1360 electronic mother/child weighing scales) and distributed among the three regions.

Mali Coverage of surveillance activities Number of districts covered 65/65 Number of women 6 496 799 age 15-49 Number of children under 5 3 248 400

PROGRESS IN CIP OBJECTIVES IMPLEMENTATION REVIEW AND VALIDATION OF NUTRITION SURVEILLANCE TOOLS A national workshop held in February 2016 provided a venue for health officers from regions and districts to exchange on challenges and lessons learnt when using the HMIS tools that had been revised to include nutrition indicators. Discussions led to changes aiming to improve the understanding of and reporting on the identified indicators. SUPERVISION OF TRAINED HEALTH AGENTS ON USE OF NUTRITION SURVEILLANCE TOOLS Supervisory visits were carried from May to August 2016 in all regions, with the exception of the north of the country for security reasons. The visits reinforced health worker skills on anthropometric measurements and on the use of HMIS tools for more accurate and reliable nutrition data.

CHILD GROWTH CARDS FINALIZED AND VALIDATED A required revision of child health cards provided the opportunity to integrate the 2006 WHO Growth Standards for girls and boys. The process was finalized and validated through a national workshop in September 2016. DISCUSSIONS ON INTEGRATION NUTRITION DATA IN IDSR Due to the emergency situation, cases of acute malnutrition (moderate and severe) are identified and reported weekly in the emergencies database. Discussions were held with the MoH in 2016 to assess the potential for integrating this emergency system into the national IDSR. This could be a component of a future project.

WFP/Sébastien Rieussec

Mozambique Coverage of surveillance activities Number of districts covered 5/128 Number of women 279 526 age 15-49 Number of children under 5 158 605

PROGRESS IN CIP IMPLEMENTATION REVIEW AND FINALIZATION OF THE NEW CHILD HEALTH AND NUTRITION REGISTER BOOK AND FORMS PRIOR TO PILOT TESTING Health facility registers for sick child visits will include information on anaemia, underweight and stunting. For well child visits they will cover exclusive breastfeeding, complementary feeding, underweight, stunting, overweight, obesity, severe acute malnutrition, moderate acute malnutrition, vitamin A supplementation, micronutrient powder supplementation and deworming. The indicator for iron folic acid supplementation for adolescent girls was moved to the register for the adolescent health programme. TRAINING DISTRICT HEALTH PROFESSIONALS Materials and presentations were prepared and reviewed. Forty eight health workers (39 female) from ANI districts were trained on the use of the new register books and data collecting forms.

PILOT IMPLEMENTATION OF THE NEW CHILD HEALTH AND NUTRITION REGISTER BOOK AND FORMS Protocols for the pilot study and data collection were prepared and reviewed. The six-week pilot implementation phase designed to inform the national scale-up plan will be initiated in early 2017 in four provinces: Cabo Delgado (Chiure District and Pemba City), Zambézia (Icidua Health Center in Quelimane City and Alto Molocue District), Inhambane (Inhambane District) and Maputo (Boane District and Jose Macamo Health Centre). END-LINE PERCEPTION SURVEY AND PERFORMANCE MONITORING FRAMEWORK The standard data collection tools were revised, and the performance monitoring framework was updated. Data will be transmitted to WHO headquarters for further analysis and comparison across ANIsupported countries. The Nutrition Evaluation Platform for data analysis is a new approach to compiling and analysing data, and can be used for data quality assessment and analysis.

Rwanda Coverage of surveillance activities Number of districts 30/30 covered Number of women 2 461 128 age 15-49 Number of children 1 540 027 under 5

PROGRESS IN CIP IMPLEMENTATION SUPERVISION AND FEEDBACK TO DISTRICTS ON DEVELOPING REGULAR FOOD AND NUTRITION BULLETINS In collaboration with UNICEF, WHO provided support for a threeday training workshop on the use of Devinfo1 for 46 nutritionists (23 men and 23 women) and for reviewing and improving the Food and Nutrition bulletins being produced by the districts. A total of 15 districts produced bulletins, which were reviewed by the MoH and Rwanda Biomedical Center with WHO and UNICEF support. SUPPORTIVE SUPERVISION FOR APPROPRIATE DATA COLLECTION AT COMMUNITY AND FOR DATA AGGREGATION AT HEALTH FACILITY LEVEL Supportive supervision was provided by the MoH/Rwanda Biomedical Center using a data quality assessment approach in 41 of the country’s 44 district hospitals and in 41 of 478 randomly selected health centres and related communities. The approach focuses on the application of national screening guidelines for acute malnutrition at 1

DevInfo is a database developed by UNICEF and endorsed by the United Nations Development Group for monitoring human development, specifically the Millennium Development Goals (MDGs).

community level and referral of cases with severe acute malnutrition to health facility level. According to the report, the nutritional status of 82% of children under 5 years of age is appropriately assessed using anthropometric measurements and indicators, and 79% of cases of acute malnutrition are treated according to national guidelines. Based on this, it is recommended to: strengthen the coverage and quality of using anthropometry in health facilities and related catchment communities in the less-well-performing areas, and integrate growth monitoring into the immunization programme; strengthen the capacity of health care providers to manage malnutrition and reinforce data sharing for decision making at district level; SURVEY REPORT AND PUBLICATION ON CAUSES OF STUNTING The Rwanda Agriculture Board launched and disseminated the survey report in April 2016. The WHO Country office, in collaboration with the MoH and the International Center for Tropical Agriculture, is developing a related manuscript on “Risk factors for stunting in infants and young children in Rwanda”.

Courtesy of Pablo Migone

Global Nutrition Targets 2025 Countries are facing complex overlays of malnutrition burdens that need concentrated action at the policy, health system and community levels. As part of its efforts to support countries, WHO developed a series of six policy briefs, one for each of the Global Nutrition Targets. Because the six targets are interlinked, single actions can help make progress toward multiple targets. The purpose of these briefs is to consolidate the evidence around which actions and areas of investment should be scaled up, and to guide decision-makers on the best ways to improve maternal, infant and young child nutrition. In the context of the ANI project, the briefs for stunting, wasting, anaemia, exclusive breastfeeding and low birth weight were used to support the review of national nutrition policies and the development of multisectoral or targeted strategic plans. http://www.who.int/nutrition/globaltargets_indicators/en/ WHO/NMH/NHD/14.3 WHO/NMH/NHD/14.4 WHO/NMH/NHD/14.5

Global Nutrition Targets 2025

Stunting Policy Brief TARGET: 40% reduction in the number of children under-5 who are stunted WHO/Antonio Suarez Weise

Global Nutrition Targets 2025

Anaemia Policy Brief TARGET: 50% reduction of anaemia in women of reproductive age WHO/Pallava Bagla

Global Nutrition Targets 2025

Low Birth Weight Policy Brief

TARGET: 30% reduction in low birth weight

Gates/Frederic Coubert

hildhood stunting is one of the most significant impediments to human development, globally affecting approximately 162 million children under the age of 5 years. Stunting, or being too short for one’s age, is defined as a height that is more than two standard deviations below the World Health Organization (WHO) child growth standards median (3). It is a largely irreversible outcome of inadequate nutrition and repeated bouts of infection during the first 1000 days of a child’s life. Stunting has long-term effects on individuals and societies, including: diminished cognitive and physical development, reduced productive capacity and poor health, and an increased risk of degenerative diseases such as diabetes (4). If current trends continue, projections indicate that 127 million children under 5 years will be stunted in 2025. Therefore, further investment and action are necessary to attain the 2025 World Health Assembly target of reducing that number to 100 million.

Stunting is a well-established risk marker of poor child development. Stunting before the age of 2 years predicts poorer cognitive and educational outcomes in later childhood and adolescence (5, 6), and has significant educational and economic consequences at the individual, household and community levels. Recent longitudinal studies of children from Brazil, Guatemala, India, the Philippines and South Africa associated stunting with a reduction in schooling, where adults who were stunted at the age of 2 years completed nearly one year less schooling than non-stunted individuals (7, 8). Similarly, a study of Guatemalan adults found that those who were stunted as children had less total schooling, lower test performances, lower household per capita expenditure and a greater likelihood of living in poverty (9). For women, stunting in early life was associated with a lower age at first birth and a higher number of pregnancies and children (10). According to World Bank estimates,

naemia (see Boxes 1 and 2) impairs health and wellbeing in women and increases the risk of maternal and neonatal adverse outcomes. Anaemia affects half a billion women of reproductive age worldwide. In 2011, 29% (496 million) of non-pregnant women and 38% (32.4 million) of pregnant women aged 15–49 years were anaemic (3). The prevalence of anaemia was highest in south Asia and central

and west Africa (3). While the causes of anaemia are variable, it is estimated that half of cases are due to iron deficiency. In some settings, considerable reductions in the prevalence of anaemia have been achieved; however, overall, progress has been insufficient. Further actions are required to reach the World Health Assembly target of a 50% reduction of anaemia in women of reproductive age by 2025 (4, 5).

BOX 1: WHAT IS ANAEMIA? Anaemia is a condition in which the number and size of red blood cells, or the haemoglobin concentration, falls below an established cut-off value, consequently impairing the capacity of the blood to transport oxygen around the body. Anaemia is an indicator of both poor nutrition and poor health. Anaemia and iron deficiency reduce individuals’ wellbeing, cause fatigue and lethargy, and impair physical capacity and work performance. Median losses in physical productivity due to iron deficiency are important (6). Failure to reduce anaemia worldwide consigns millions of women to impaired health and quality of life, generations of children to impaired development and learning, and communities and nations to impaired economic productivity and development. Maternal anaemia is associated with mortality and morbidity in the mother and

ow birth weight is defined by the World Health Organization (WHO) as weight at birth less than 2500 g (5.5 lb). Low birth weight continues to be a significant public health problem globally and is associated with a range of both short- and longterm consequences. Overall, it is estimated that 15% to 20% of all births worldwide are low birth weight, representing more than 20 million births a year. The goal is to achieve a 30% reduction in the number of infants born with a weight lower than 2500 g by the year 2025 (1). This would translate into a 3% relative reduction per year between 2012 and 2025 and a reduction from approximately 20 million to about 14 million infants with low weight at birth. Preterm birth is the most common direct cause of neonatal mortality (3). Every year, 1.1 million babies die from complications of preterm birth. Low birth weight is not only a major predictor of prenatal mortality and

morbidity, but recent studies have found that low birth weight also increases the risk for noncommunicable diseases such as diabetes and cardiovascular disease later in life (4, 5). There is considerable variation in the prevalence of low birth weight across regions and within countries; however, the great majority of low-birth-weight births occur in low- and middle-income countries and especially in the most vulnerable populations (6, 7). Regional estimates of low birth weight include 28% in south Asia, 13% in sub-Saharan Africa and 9% in Latin America (see Table 1). It is worth noting that these rates are high, in spite of the fact that the data on low birth weight remain limited or unreliable, as many deliveries occur in homes or small health clinics and are not reported in official figures, which may result in an underestimation of the prevalence of low birth weight.

WHO/NMH/NHD/14.6

WHO/NMH/NHD/14.7

WHO/NMH/NHD/14.8

Global Nutrition Targets 2025

Childhood Overweight Policy Brief TARGET: No increase in childhood overweight

Global Nutrition Targets 2025

Breastfeeding Policy Brief

Global Nutrition Targets 2025

Wasting Policy Brief TARGET: Reduce and maintain childhood wasting to less than 5% Gates/Jake Lyell Gates/Peter DiCampo

TARGET: Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% Gates/Patricia Rincon

WHAT’S AT STAKE In 2012, the World Health Assembly Resolution 65.6 endorsed a Comprehensive implementation plan for maternal, infant and young child nutrition (1), which specified six global nutrition targets for 2025 (2). This policy brief covers the fourth 1 target: no increase in childhood overweight. The purpose of this policy brief is to increase attention to, investment in, and action for a set of cost-effective interventions and policies that can help Member States and their partners prevent continued increases in overweight in children and ensure that the target is met. here has been a dramatic rise in the numbers of children under 5 years of age who are overweight. According to the new 2013 United Nations Children’s Fund (UNICEF), World Health Organization (WHO) and World Bank estimates (4), between 2000 and 2013, the number of overweight children worldwide increased from 32 million to 42 million. The prevalence of childhood overweight is increasing in all regions of the world, particularly in Africa and Asia. Between 2000 and 2013, the prevalence of overweight in children under 5 years of age increased from 1% to 19% in southern Africa, and from 3% to 7% in south-east Asia. In terms of regional breakdowns in numbers of overweight children in 2013, there were an estimated 18 million overweight children under 5 years of age in Asia, 11 million in Africa and 4 million in Latin America and the Caribbean. Low levels of overweight in children under 5 years of age were observed in the regions of Latin America and the Caribbean, with little change over the last 13 years. Nevertheless, countries with large populations, such as Argentina, Brazil, Chile, Peru 1

WHAT’S AT STAKE In 2012, the World Health Assembly Resolution 65.6 endorsed a Comprehensive implementation plan on maternal, infant and young child nutrition (1), which specified six global nutrition targets for 2025 (2). This policy brief covers the sixth target: reduce and maintain childhood wasting to less than 5%. The purpose of this policy brief is to increase attention to, investment in, and action for a set of cost-effective interventions and policies that can help Member States and their partners to reduce and maintain the rate of childhood wasting. he global target for 2025 will be achieved if highburden countries take stock of their current prevalence, projected population growth, underlying causes of wasting and the resources available to address them; set target annual reduction rates to guide intervention efforts; mobilize necessary resources; and develop and implement systematic plans for the reduction of wasting. In addition, all countries need to examine inequalities among populations and identify priority actions for particular vulnerable or marginalized groups, where there are clusters of large numbers of wasting children. Such an equity-inspired approach is both an ethical imperative and a judicious investment strategy. Wasting is a major health problem and, owing to its associated risks for morbidity, requires urgent attention from policy-makers and programme implementers alike. Addressing wasting is of critical importance because of the heightened risk of disease and death for children who

and the Plurinational State of Bolivia, observed levels of 7% and higher. If these increasing trends continue, it is estimated that the prevalence of overweight in children under 5 years of age will rise to 11% worldwide by 2025, up from 7% in 2012 (5). Children who are overweight or obese are at a higher risk of developing serious health problems, including type 2 diabetes, high blood pressure, asthma and other respiratory problems, sleep disorders and liver disease. They may also suffer from psychological effects, such as low self-esteem, depression and social isolation. Childhood overweight and obesity also increase the risk of obesity, noncommunicable diseases (NCDs), premature death and disability in adulthood. Finally, the economic costs of the escalating problem of childhood overweight and obesity are considerable, both in terms of the enormous financial strains it places on health-care systems and in terms of lost economic productivity.

xclusive breastfeeding – defined as the practice of only giving an infant breast-milk for the first 6 months of life (no other food or water) – has the single largest potential impact on child mortality of any preventive intervention (3). It is part of optimal breastfeeding practices, which also include initiation within one hour of life and continued breastfeeding for up to 2 years of age or beyond. Exclusive breastfeeding is a cornerstone of child survival and child health because it provides essential, irreplaceable nutrition for a child’s growth and development. It serves as a child’s first immunization – providing protection from respiratory infections (4), diarrhoeal disease, and other potentially life-threatening ailments. Exclusive breastfeeding also has a protective effect against obesity and certain noncommunicable diseases later in life (4). Yet, much remains to be done to make exclusive breastfeeding during the first 6 months of life the norm

for infant feeding (see Box 1). Globally, only 38% of infants aged 0 to 6 months are exclusively breastfed (5, 6). Recent analyses indicate that suboptimal breastfeeding practices, including non-exclusive breastfeeding, contribute to 11.6% of mortality in children under 5 years of age. This was equivalent to about 804 000 child deaths in 2011(5). It is possible to increase levels of exclusive breastfeeding. Between 1985 and 1995, global rates of exclusive breastfeeding increased by 2.4% per year on average (increasing from 14% to 38% over 10 years) but decreased subsequently in most regions. However, 25 countries increased their rates of exclusive breastfeeding by 20 percentage points or more after 1995, a rate that is similar to what is needed to achieve the global target (7, 8). Countries already at or near 50% exclusive breastfeeding should continue to strive for improvements because of the health and economic benefits of exclusive breastfeeding. In these cases, we suggest a minimum increase of 1.2% per year or more.

lose too much of their body weight. It will be difficult to continue improving rates of child survival without improvements in the proportion of wasted children receiving timely and appropriate life-saving treatment, alongside reductions in the number of children becoming wasted in the first place (prevention). The World Health Organization (WHO) classifies wasting in children as severe or moderate, according to the WHO growth reference for weight-for-height (3). This definition does not include children with bilateral pitting oedema – a form of acute undernutrition that results from similar causal pathways to wasting. Wasting is a reduction or loss of body weight in relation to height. Acute malnutrition in children aged 6 to 59 months can be either moderate or severe. Severe acute malnutrition is defined as severe wasting (low weightfor-height) and/or mid-upper arm circumference (MUAC) <115 mm and/or bilateral pitting oedema. Moderate acute malnutrition is defined as moderate wasting and/or MUAC

Overweight in children under 5 years of age is defined as weight-for-height >+2 standard deviations of the World Health Organization (WHO) child growth standards median (3).

Senegal Coverage of surveillance activities Number of districts 76 /76 covered Number of women age 15-49 Number of children under 5 5 403 485 2 701 743

PROGRESS IN CIP IMPLEMENTATION FOLLOW UP ON NATIONAL NUTRITION DATA THROUGH IDSR The support provided by ANI during the reporting period made it possible to extract weekly nutrition data, specifically on deaths related to cases of acute malnutrition. A sudden increase could indicate a food crisis. Most districts provided timely data for aggregation at the national level. A system has been developed to share data with the WHO regional office for inclusion in the rSIS when the nutrition module will become available. SETTING UP OF NUTRITION INDICATORS WITHIN HMIS/DHIS2 The recently revised HMIS system is gradually becoming functional. Nutrition indicators to be integrated within the system, identified in early stages of ANI implementation, were incorporated in 2016. This process is allowing progressive access to routine nutrition data. However, the system needs to be monitored and followed up to evaluate data reliability, and training will soon be required to ensure that health workers at national level fill the HMIS forms correctly.

Phil Behan/WFP

SENTINEL SURVEILLANCE The sentinel surveillance system in nutrition, which was systematized in 2016, now makes it possible to have nutrition data from several sources and partners at once. This allows a more complete picture of the nutrition situation in the five sentinel sites. The Nutrition Division of the MoH, in collaboration with WHO and the IPDSR1, carried out the second and third rounds of the sentinel nutrition surveillance survey, and provided refresher training for data collection to get accurate information. Data were analysed with WHO support.

IPDSR: Institut de Population, Développement et Santé de la Reproduction / Institute for Population, Development, and Reproductive Health (Cheikh Anta Diop University, Dakar).

Sierra Leone Coverage of surveillance activities Number of districts 13/13 covered Number of women 1 621 058 age 15-49 Number of children under 5 1 204 840

PROGRESS IN CIP IMPLEMENTATION TRAINING ON GROWTH MONITORING AND PROMOTION As the country moved towards the recovery phase of the Ebola outbreak, emphasis was placed on strengthening the health system. One key area was building the capacity of staff to implement the basic package of essential health services. Training on Growth Monitoring and Promotion (GMP) was conducted for 200 health workers, representing 16% of peripheral health units (PHUs). Training was done using the previously revised training manual on GMP to enable the efficient and accurate measurement and interpretation of children’s growth status, counselling sessions with caregivers on age appropriate infant and young child feeding and facilitation of timely referral of children with acute malnutrition. The aim is to have at least one trained staff in each facility to support GMP activities. To date, 72% of PHUs in the country have a trained staff on GMP through the ANI project. SUPPORTIVE SUPERVISION As a follow-up to training, supportive supervision was conducted at PHU level to ensure that the techniques and skills on GMP were adhered to by health workers. These sessions are used to ascertain

the retention of skills, monitor the quality of data collected and providing guidance on the job, thereby improving the quality of monthly reports produced. MICRONUTRIENT SURVEY Acting on the findings from the national micronutrient survey, which found a high prevalence of anaemia among women and children, the Food and Nutrition Directorate established a national anaemia working group. A national strategy on the prevention and control of anaemia was drafted, to be finalized by May 2017, and a pilot study on the use of micronutrient powders for children under 2 years of age was implemented in two districts. Two articles based on extracts from the survey were published in international journals.1 NUTRITION SURVEILLANCE A nutrition surveillance committee was established to review quarterly surveillance report for dissemination and action. A database on functional anthropometric tools available in all health facilities is updated on yearly basis to help identify gaps and facilitate timely replacement by the Ministry of Health and Sanitation (MoHS) and its partners. At community level, mothers are now able to use the MUAC tape to self-screen their children. As a complement, innovations of colour-coded length-for-age and height-for-age boards are being used in community trials and primary health facilities to screen for stunting. The first trials in five communities were encouraging, and a roll-out is planned to an additional five communities. NUTRITION SURVEILLANCE REPORTS The Directorate of Food and Nutrition received support to conduct the 2015 Annual nutrition review meeting and develop the 2016 action plan. To facilitate monitoring malnutrition trends, technical guidance was provided to analyse nutrition surveillance data and to produce the 2015 annual report and 2016 quarterly reports. These were disseminated to nutrition stakeholders at national level to inform programmatic action. 1

Courtesy of Robin Lustig

http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0155031; http://www.mdpi.com/2072-6643/8/2/74

DEVELOPMENT OF THE CHILD HEALTH CARD USER GUIDE A pocket guide was developed to address the challenges faced by health workers in filling out the child health card. The guide includes instructions on plotting the growth chart as per the 2006 WHO Growth Standards, recording general information as well as birth weight, routine vitamin A supplementation and immunization, and hints for counselling sessions on complementary feeding, hygiene and sanitation. 1400 copies of the pocket guide were printed for dissemination to all PHUs across the country. The guide will serve as a quick reference for health care providers when monitoring the health and nutritional status of children. ANTHROPOMETRIC TOOL INVENTORY A national database on the availability of functional anthropometric tools in health facilities was developed through ANI and an inventory is conducted yearly to monitor the status. This helps to identified stock-outs of tools, and provides an indication of the type of tools needed, the quantity required and means of distribution. CAPACITY BUILDING OF NUTRITION OFFICERS ON SURVEILLANCE Refresher training on nutrition surveillance, which includes GMP, was conducted for 49 nutrition officers from the MoHS as well as for implementing partners. Trained staff should be able to effectively support and monitor the implementation of nutrition surveillance activities at district, community and facility levels, produce analytical nutrition surveillance reports and take prompt action as required. END-LINE PERCEPTION SURVEY This survey aimed to identify how the nutrition situation is perceived by partners, health workers and the media, how nutrition data is collected and analysed, and the current capacities at country level to implement interventions. The report showed that the perception of health workers on nutrition surveillance activities has improved, in particular on the use of WHO Growth Standards. Most respondents indicated feeling confident in all or most aspects of nutrition surveillance as compared to the 2014 baseline.

Courtesy of Rachel Unkovic/IRC

Uganda Coverage of surveillance activities Number of districts covered 6/111 Number of women age 631 199 15-49 Number of children under 5 562 590

Masindi Hoima Kibaale Namutumba Luaka Iganga

B B

PROGRESS IN CIP IMPLEMENTATION

HEALTH WORKERS FROM ALL LEVELS WERE TRAINED ON THE REVISED HMIS TOOLS AND REGISTERS Training highlighted the key nutrition data elements to be tracked as well as nutrition status assessment. 100% of all health facilities across the six districts were represented. POST-TRAINING MENTORSHIP AND SUPPORTIVE SUPERVISION WERE PROVIDED TO HEALTH WORKERS IN 288 FACILITIES (100% COVERAGE) This ensures that quality nutrition data are not only collected but also used for decision making. It was vital for identifying challenges to strengthening nutrition surveillance in each of the project districts.

A MULTISECTORAL ADVOCACY MEETING This meeting was held in each of the six core ANI districts to share progress on nutrition surveillance, strengths and challenges, and to discuss the sustainability and scale-up of activities under the ANI project. The 215 participants (of whom 75 are female) represented government ministries including, among others, Agriculture, Fisheries and Education. District authorities reiterated their commitment to nutrition and to continuing surveillance activities after the end of the ANI project. FOUR NUTRITION BULLETINS These bulletins, describe the process and results of integrating key nutrition indicators in the DHIS2 were produced and disseminated for advocacy to district health and development committees. These bulletins, aimed at gaining stakeholder buy-in and support for nutrition surveillance, show the “before” and “after” status of nutrition data in the DHIS 2, challenges and recommendations. NUTRITION SURVEILLANCE WAS EXTENDED Fourteen neighbouring districts were added, and received WHO support to capacity building for district level health teams on DHIS 2 and on data quality, demand and use. A REVIEW OF COMMUNITY HMIS TOOLS This review was done to include data elements from the World Health Assembly 2012 Global Nutrition Targets; this also helped establish linkages between the community and the health facility for collecting and using nutrition data. Specific data elements included those on introduction of breastfeeding within one hour of birth, exclusive breastfeeding, number of antenatal visits, number of pregnant women taking iron/folate, number of children stunted and the number of children with oedema. THE MOH WAS PROVIDED WITH PRINTED MATERIALS These include revised registers, Z-score charts and anthropometric equipment for all six ANI districts. Courtesy of amigos.org.uk

United Republic of Tanzania Coverage of surveillance activities Number of districts covered 11/169 Number of women 1 234 112 age 15-49 Number of children under 5 408 828

PROGRESS IN CIP IMPLEMENTATION ANTHROPOMETRIC EQUIPMENT Equipment (weight/length boards, weighing scales and MUAC tapes) procured previously was distributed to 13 hospitals, 40 health centres and 360 dispensaries in the two focus regions. ONE-DAY REFRESHER TRAINING In March 2016, refresher training was conducted for 12 District Nutrition Officers and 12 District HMIS Officers on using the anthropometric equipment and on HMIS nutrition data tools. Eight of the 24 participants are female. This was followed by one-day demonstration sessions involving 413 health workers, of whom 39% are female. 28 Nutrition officers and HMIS officers (10 women and 18 men) were also oriented on nutrition scorecards. OVERVIEW SURVEY This survey indicated that more than 90% of the centres had received the equipment, and about 70% reported having started to use it. Only half were using nutrition data recording forms distributed

during training to collect data for the HMIS, since the finalized forms have yet to be printed and distributed by MOH. THE ANI EFFORT TO INSTITUTIONALIZE ROUTINE GROWTH ASSESSMENT IN NUTRITION SURVEILLANCE This was done in conjunction with the WHO-supported Healthy Growth Project. Twenty-eight facilitators (18 women) were trained on the WHO Child Growth Standards and 28 health workers (18 male and 10 females) were trained as trainers on the use of anthropometric equipment and HMIS nutrition surveillance data tools. This was followed by a five-day district-level orientation on the growth standards for 511 health workers (27% female) from 15 hospitals, 40 health centres and 386 dispensaries. ROUTINE MONITORING AND SUPERVISION TOOLS IN THE TWO REGIONS WERE REVISED In order to ensure a sustainable monitoring system, existing routine monitoring and supervision tools in the two regions were revised to incorporate nutrition indicators. These were piloted during integrated reproductive and child health monitoring and supervision visits to health facilities to assess the progress of delivery of scale-up nutrition interventions. NATIONAL MULTI-SECTORAL NUTRITION ACTION PLAN WHO and partners also supported the Government to develop a National Multi-sectoral Nutrition Action Plan. It covers maternal, infant and young child nutrition, micronutrients, integrated management of acute malnutrition, diet-related noncommunicable diseases, nutrition-sensitive interventions, nutrition governance, and a multi-sectoral information system. The revised National Food and Nutrition Policy will be presented to the Parliament for endorsement.

Courtesy of blogs.elca.org

Zambia Coverage of surveillance activities Number of districts covered 14/89 (1-2 districts per region) Number of women age 1 528 538 15-49 Number of children under 5 546 900

PROGRESS IN CIP IMPLEMENTATION FINALIZATION OF THE ZAMBIA NUTRITION INFORMATION SYSTEM (ZAMNIS) AND ESTABLISHMENT OF 30 SENTINEL SITES FOR COLLECTING NUTRITION DATA TO FEED INTO THE ZAMNIS ANI steered a national stakeholder dialogue to reach consensus on which nutrition indicators to include in the HMIS. The indicators include anthropometry (stunting, wasting, underweight, obesity and low birth weight), vitamin A and iron supplementation, deworming and infant feeding. This was followed by an orientation of 20 provincial nutritionists and information officers (five women) and 14 district nutritionists and information officers (four women) on how to collect information for the indicators and use DHIS2 in data analysis and presentation. TARGETED DISTRICTS In the four targeted districts where collection of height indicator data has been initiated, a total of 24 nutrition focal persons and information officers (nine women) were oriented on growth

assessment and use of DHIS2 for data review and analysis. For the 40 targeted health facilities, similar training was provided for four health workers per facility for a total of 160 (40 woman). IDENTIFICATION OF GAPS IN THE SURVEILLANCE SYSTEM AT COMMUNITY LEVEL AND LINKAGES WITH THE ZAMNIS A scoping exercise was commissioned to ascertain the needs and requirements for development of the ZamNIS. Results will be available in early 2017. A scale-up plan for the GMP programme and guidance for GMP implementation are under development. These will strengthen nutrition surveillance, given that GMP is the point of contact at which information is collected. TECHNICAL AND SPILL-OVER EFFECT OF WHO TECHNICAL ASSISTANCE The ANI project increased WHO’s visibility as a partner in the national nutrition arena. WHO was solicited to contribute to initiatives which, though not part of the CIP objectives, strengthened collaboration in nutrition in a way that is likely to sustain and multiply the impact of the project.

Courtesy of DFID

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Made a presentation to the parliamentary committee for health, community development and social services to advocate for strengthening nutrition in the health sector; Provided technical assistance for the development of an accountability framework that will be used to track resource allocation and use at primary health care level; Mobilized resources (US $20 000) and provided technical assistance to develop the revised National Food and Nutrition Sector Strategic Plan; With the World Food Programme, developed a proposal to help mobilize resources and procure technical assistance for the National Food and Nutrition Commission (NFNC). Based on this, the Micronutrient Initiative Technical Assistance Organization provided support for technical assistance to the NFNC in the Monitoring and Evaluation component of cross-sectoral efforts to reduce stunting;

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Supported the development of a module on managing nutrition programmes, and trained eight provincial and 14 (four women) district nutritionists on its use. With the NFNC and MoH, developed a proposal for evaluating micronutrient status and advocated for a Ministry of Finance allocation of US $300 000 to the MoH. In preparation for the revision and development of the National Nutrition Sector Strategic Plan, supported the orientation of five male and 20 female national staff from the MoH, the National Food and Nutrition Commission, and cooperating partners on the use of WHO nutrition policy and planning tools for decisionmaking. Hosted the Regional Training Workshop for WHO Technical Officers from 14 African countries in the In-Patient Management of Severe Acute Malnutrition, with the participation of eight Zambian nutrition/nursing officers.

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Courtesy of wowmission.com

Zimbabwe Coverage of surveillance activities Number of districts covered 10/59 (1 district per region) Number of women age 332 145 15-49 Number of children under 5 225 294

PROGRESS IN CIP IMPLEMENTATION NATIONAL FOOD CONSUMPTION SURVEY REPORT The finalization of the survey report from 2015 took longer than anticipated. Comments from the most recent review by WHO were sent to the MoH at the beginning of November 2016 and it is anticipated that the report will be finalized and cleared for dissemination by March 2017. Preliminary findings were used to refine the food fortification strategy. STRENGTHENING OF THE NUTRITION SURVEILLANCE SYSTEM A SMART survey was carried out with WHO support to quantify the magnitude of malnutrition as a result of the El Niño-induced drought in the country. Using routine nutrition data generated by DHIS2, acute malnutrition is now among the indicators included in weekly monitoring reports. In the same context, monthly screening for acute malnutrition is being done in the districts most affected. Monthly nutrition reports are also being produced to inform district

teams on the coverage of key nutrition interventions for feedback and action. WHO supported Zimbabwe’s vulnerability assessment in the context of the El Niño drought. The assessment helped to identify vulnerable districts to target for hunger relief. END-LINE PERCEPTION SURVEY The MoH conducted the end-line perception survey and transmitted the data to WHO for analysis and reporting. Courtesy of wefa.org.uk

Part IV: Management Financial Report Expenditures as of 30 September 2016 as per approved grant budget Description Direct Project Activities Regional and Global Activities Monitoring and Evaluation Project Administration Total Total Expenditures January – September 2016 CAN$ CAN$ CAN$ CAN$ CAN$ 841 419 592 414 23 894 189 504 1 647 232

According to the final certified financial statement signed off by the WHO Chief Finance the amount of USD$ 30 075 is the residual balance of the surveillance project. With the permission of Global Affairs Canada, this amount was reprogrammed towards the partners and implementers’ meeting for early 2017 to discuss and share lessons learnt from ANI, collect end-line data required from the Performance Monitoring Framework, and prepare the two annual and two final reports. A detailed breakdown of the project’s expenditures from beginning to end is included in the final surveillance report.

For more information, please contact: Department of Nutrition for Health and Development World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4156 Email: nutrition@who.int www.who.int/nutrition

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 16 mai 2017

Source Organisation mondiale de la santé