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Accelerating nutrition improvements in sub-Saharan Africa (ANI): report of the baseline and end-line perception surveys in ten countries

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Accelerating Nutrition Improvements in sub-Saharan Africa (ANI) Report of the baseline and end-line perception surveys in ten countries

Accelerating nutrition improvements in sub-Saharan Africa (ANI): report of the baseline and end-line perception surveys in ten countries ISBN 978-92-4-151208-4 © 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. Accelerating nutrition improvements in sub-Saharan Africa (ANI): report of the baseline and endline perception surveys in ten countries. Geneva: World Health Organization; 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. Edited by Cathy Wolfheim Design and layout by Sue Hobbs Printed in Switzerland

Contents

Acknowledgements Abbreviations Executive Summary I. II. Introduction Methods Survey tools Timing of surveys Implementation of surveys in countries Global level analyses Assessment of the ANI PMF indicators PMF Intermediate outcome 1300: Awareness of the country’s nutrition situation PMF Immediate outcome 1120: Government capacity for nutrition surveillance PMF Immediate outcome 1220: Health workers’ capacity to deliver nutrition interventions PMF Intermediate outcome 1100: Health workers’ capacity and confidence to do nutrition surveillance

vii viii iv 1 2 2 2 3 3 3 3 3 5 5 6 6 6 6 8 15 17 17 20 20 20 20 24 26 27 29 30 REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

III. Results Responses Perception of the nutrition situation and priorities in countries Awareness of Global Nutrition Target-related problems in countries Awareness of nutrition problems and causes beyond the Global Nutrition Targets Government priority for nutrition Government capacity for nutrition surveillance Nutrition data being collected Use of nutrition data

Perception of nutrition surveillance

Perception of health worker capacity for delivering nutrition services and performing nutrition surveillance Health workers’ capacity to deliver nutrition interventions Health worker training Health workers’ capacity and confidence to do nutrition surveillance

Summary of survey results References

IV. Discussion and conclusion

iii

List of Tables Table 1. Questionnaire tools, target groups and recommended sample sizes per country Table 2. Country data related to the 2025 Global Nutrition Targets: prevalence and year Table 3. Cut-off values used to determine country-relevant nutrition problems Table 4. Number of respondents by respondent group Table 5. Summary of baseline and end-line values for ANI PMF perception indicators 2 4 5 7 28

List of Figures Figure 1. Indicator 1300: Awareness of a majority of country-relevant problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) Figure 2. Problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) Figure 3. Problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by type of respondent (n= 450 at baseline, 298 at end-line) Figure 4. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development practitioners and media (n= 450 at baseline, 298 at end-line) Figure 5. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) Figure 6. Causes of nutrition problems as perceived by respondents representing government at national and district level, development practitioners and media (n= 450 at baseline, 298 at end-line) Figure 7. Causes of nutrition problems as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) Figure 8. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line (n=767 at baseline, 167 at end-line) Figure 9. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line, by country (n=767 at baseline, 167 at end-line) Figure 10. Government priority for nutrition as perceived by all respondents in ten countries at baseline and in three countries at end-line, by type of respondent (n=767 at baseline, 167 at end-line) Figure 11. Health workers’ perception of priority given to nutrition by decision-makers and by themselves in their daily work in ten countries at baseline and in three countries at end-line (n=317 at baseline, 61 at end-line)

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Figure 12. Indicator 1120: Perceived “high” or “very high” government capacity for nutrition surveillance as reported by respondents representing government at national and district level and development practitioners, by country (n=395 at baseline, 298 at end-line) Figure 13. Government capacity for nutrition surveillance as perceived by respondents representing government at national and district level and development practitioners, by country (n=395 at baseline, 298 at end-line) Figure 14. Government capacity for nutrition surveillance as perceived by respondents representing government at national and district level and development practitioners, by type of respondent (n=395 at baseline, 298 at end-line) Figure 15. Government capacity for various aspects of nutrition surveillance as perceived by respondents representing government at national and district level and development practitioners (n=395 at baseline,298 at end-line) Figure 16. Collection of Global Nutrition Target indicators as reported by government respondents at national and district levels and health workers (n=615) Figure 17. Collection of 2025 Global Nutrition Target indicators as reported by government at national and district levels and health workers, by country (n=615) Figure 18. Uses of nutrition data collected as reported by government respondents at national and district levels (n=298) Figure 19. Perception of nutrition information as reported by media respondents (n=55) Figure 20. Indicator 1220: Correct knowledge on at least six out of eight questions related to the delivery of nutrition services among health workers in the three scale-up countries, by country (n=115 at baseline, 79 at end-line) Figure 21. Correct knowledge on delivery of various nutrition services, as reported health workers in the three scale-up countries, by country (n=115 at baseline, 79 at end-line) Figure 22. Training and perceived training needs among health workers in ten countries at baseline (n=317) Figure 23. Health worker knowledge of and confidence to carry out IYCF intervention in ten countries at baseline, by breastfeeding training status (n=317) Figure 24. Health worker knowledge of and confidence to manage SAM in ten countries at baseline, by SAM management training status (n=317) Figure 25. Indicator 1100: Confidence in most or every aspect of implementing four nutrition surveillance activities as perceived by health workers in ten countries, by country (n=317) Figure 26. Confidence in implementing four nutrition surveillance activities as perceived by health workers in ten countries, by nutrition surveillance training status (n=317) Figure 27. Health worker knowledge about WHO Growth Standards in ten ANI countries, by nutrition surveillance training status (n=317)

19 20 21 21 22

22 REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

23 24 25 26

26 27 27

Acknowledgements

The development of the perception surveys and preparation of this report were led by Ms Kaia Engesveen with technical inputs and support from Dr Hana Bekele, Dr Férima Coulibaly-Zerbo and Dr Elisa Dominguez. Appreciation is extended to the larger WHO team, including Ms Monika Bloessner, Dr Francesco Branca, Dr Mercy Chikoko, Dr Chizuru Nishida, Dr Mercedes de Onis, Dr Adelheid Onyango and Ms Krista Zillmer, as well as to the WHO interns who supported the development of the survey tools and preparation of the report including Ms Ana Elisa Pineda, Ms Einat Schmutz, Ms Paula Veliz and Ms Line Vogt. WHO gratefully recognizes the work of Dr Jessica Fanzo (Johns Hopkins Bloomberg School of Public Health) who developed guidance for using the Performance Monitoring Framework of the project. Special thanks are also due to the WHO country office colleagues and their national counterparts who led the surveys: ■■ Burkina Faso: Dr Fousséni Dao (WHO), Ms Bertine Ouaro Dabiré and Mr Saidou Kabore (Ministère de la Santé) ■■ Ethiopia: Ms Etsegenet Assefa, Dr Kemeria Barsenga and Mr Getahun Teka Beyene (WHO), Ms Mulu Gebremedhin (John Snow, Inc.), Ms Yordanos Giday Hagos and Mr Birara Melese Yalew (Federal Ministry of Health) ■■ Mali: Dr Seybou Guindo (Ministère de la Santé), Dr Mohamed Ibrahim (Ministère de la Santé) and Dr Attaher Houzeye Toure (WHO) ■■ Mozambique: Dr Marla Amaro (Ministry of Health) and Dr Daisy Trovodada (WHO) ■■ Senegal: Dr Maty Diagne Camara (Ministère de la Santé et de l’Action Sociale), Mr Ndiaye Djibril (consultant) and Dr Fatim Tall (WHO) ■■ Sierra Leone: Dr Aminata Shamit Koroma and Dr Solade Pyne-Bailey (Ministry of Health and Sanitation) and Ms Hannah Yankson (WHO) ■■ Uganda: Dr Baku Agnes Chandia and Dr Mwebembezi Edmond (Ministry of Health), Dr Priscilla Ravonimanantsoa (WHO), Mr Ssesanga Steven (MOH), Dr Bakunzi Maureen Tumusiime (Office of the Prime Minister) and Dr Florence Turyashemererwa-Biko (WHO) ■■ United Republic of Tanzania: Dr Isiaka Stevens Alo (WHO), Ms Mwashiga Augustino (Save the Children Fund Tanzania), Mr Gilagister Gwarassa (Tanzania Food and Nutrition Center), Mr Juma Peter Kaswahili (Ministry of Health and Social Welfare), Ms Rachel Alice Makunde (Save the Children Fund Tanzania), Mr Samson Ndimaga (TFNC) ■■ Zambia: Ms Agnes Aongola (Ministry of Health), Ms Chipo Misodzi Mwela (WHO) and Ms Dorothy Sikazwe (Ministry of Health) ■■ Zimbabwe: Mr Admire Chinjekure and Dr Trevor Kanyowa (WHO), Mr Joshua Katiyo (Ministry of Health) and Mr Nyadzayo Tasiana (Ministry of Health)

vii

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

Abbreviations

ANI CSO DHS/EDS IYCF MAM MICS NGO PMF SAM SMART UN WHO

Accelerating Nutrition Improvements in sub-Saharan Africa Civil society organization Demographic and Health Survey/Enquête Démographique et de Santé Infant and young child feeding Moderate acute malnutrition Multiple Indicator Cluster Survey Nongovernmental organization Performance Monitoring Framework Severe acute malnutrition Standardized Monitoring and Assessment of Relief and Transitions United Nations World Health Organization

viii

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Executive Summary

The Accelerating Nutrition Improvements in sub-Saharan Africa (ANI) project, implemented during the period 2013–2016, focused on strengthening nutrition surveillance in 11 countries (Burkina Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe). The project was supported by Global Affairs Canada and was implemented in close collaboration between the ministry of health, the World Health Organization (WHO) and local partners in respective countries. The progress of the ANI project was assessed using a Performance Monitoring Framework (PMF), which was developed in the beginning of the project. The PMF consisted of a set of quantitative and qualitative indicators with specific project performance targets to be reached during the implementation period. Four of the qualitative indicators were related to the perceptions and capacities of stakeholders: 1. Stakeholders’ awareness of the country’s nutrition situation (target: 50%) 2. Government capacity to collect and analyse nutrition data (target: 70%) 3. Health workers’ capacity to deliver nutrition interventions (target: 75%) Information on these four indicators was gathered through “perception surveys” at the beginning and end of the project by each of the country teams. Five questionnaires were used to assess the perceptions of national and district level government representatives, development practitioners, health workers and media. Algorithms were created for aggregating the perception survey results into one indicator value per country. This report presents the results of 767 baseline and 498 end-line interviews in ten countries, and the level of achievement of the project performance targets on the four perception and capacity indicators. Rwanda was not included in the analysis, due to the timing of their interventions. The results of the perception surveys show that important perception and capacity changes can be achieved among government officials, health workers and other stakeholders in a relatively short but intense period. For instance, seven out of ten countries attained the project performance target related to awareness of the country’s nutrition situation. While stakeholders were most familiar with the problems of stunting and wasting, the awareness of problems related to anaemia, low birth weight, overweight and low rates of exclusive breastfeeding increased over the project period. Health workers’ perceptions of their capacity for delivering nutrition services and performing nutrition surveillance also increased over the project period. In all three countries supported to implement scaling-up of nutrition actions (Ethiopia, Uganda and the United Republic of Tanzania), health workers’ capacity to deliver nutrition interventions, such as infant and young child feeding counselling and the management of severe acute malnutrition, was strengthened. Furthermore, in seven out of ten countries, health workers’ capacity and confidence to perform nutrition surveillance increased. On the other hand, no country reached the project performance target concerning government capacity for nutrition surveillance. This may be attributable to the fact that the survey assessed REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

4. Health workers’ capacity and confidence to carry out nutrition surveillance (target: 50%).

stakeholders’ perceptions of government capacity rather than the government’s actual capacity to conduct nutrition surveillance. Overall, government capacity for undertaking surveys was perceived higher than the capacity for conducting routine data collection. The perception surveys can serve as important tools for assessing stakeholders’ understanding and views on nutrition problems being faced in their communities, districts or countries as well as their capacity to address those problems. This, in turn, will help to identify required actions to guide the delivery of nutrition interventions.

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

I. Introduction

The Accelerating Nutrition Improvements in sub-Saharan Africa (ANI) project, implemented during the period 2013–2016, had three components: ■■ strengthening of nutrition surveillance in 11 countries (Burkina Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, the United Republic of Tanzania, Zambia and Zimbabwe); ■■ carrying out nutrition surveys in four countries (Rwanda, Sierra Leone, Zambia and Zimbabwe); and ■■ scaling up nutrition interventions in three countries (Ethiopia, Uganda and the United Republic of Tanzania). The ANI project was supported by Global Affairs Canada and was implemented in close collaboration between the ministry of health, the World Health Organization (WHO) and local partners in respective countries. The progress of the ANI project was assessed using a Performance Monitoring Framework (PMF), developed in the beginning of the project implementation period. The framework consists of a set of quantitative and qualitative indicators, of which four concern the perceptions and capacities of different stakeholders: 1. Policy-makers, development practitioners, and media with awareness of the country’s nutrition situation, and an understanding/conviction that nutrition is a national priority for investment. 2. Government capacity to collect and analyse nutrition data collected from the surveys (those who perceive they have the knowledge and skills to collect and analyse the data). 3. Health workers’ capacity to deliver nutrition interventions to women and children in ANI districts (who perceive that their knowledge and skills have improved). 4. Health workers’ perception of their capacity (and confidence) to carry out nutrition surveillance. Information on these indicators was collected through surveys at baseline and end-line of the project. Ten of the eleven ANI countries performed the full survey at baseline and an abbreviated version at end-line. One country, Rwanda, carried out the baseline survey in October 2015 after having implemented various capacity building activities and thus did not conduct an end-line survey. This report presents the results of the surveys, hereafter referred to as “perception surveys”, in ten countries.

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

II. Methods

The perception surveys were developed based on the WHO Landscape Analysis country assessment tools and methodology,1 which have been applied in 19 countries2 to date. A detailed description of the methodology, including sampling and interview techniques, can be found in the ANI PMF Guide (WHO, 2014).

Survey tools The survey tools consisted of five questionnaires (Table 1), with corresponding data entry sheets. All five questionnaires were used to collect data at baseline, while shorter versions of four of the questionnaires3 were used at end-line. Recommended sample sizes remained the same at baseline and end-line.

Table 1. Questionnaire tools, target groups and recommended sample sizes per country QUESTIONNAIRE TOOL EXAMPLE OF TARGET GROUP RESPONDENTS RECOMMENDED SAMPLE SIZE

1. National level government ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) 2. Development practitioners 3. Media

Director of Nutrition Programme, Director of Health Promotion Department, Director of Food Security and Nutrition, School Health Manager UN, NGOs, CSOs and donors Journalists, writers, television and radio producers/creators, press District Health Manager, District Chief Health Officer, District Agriculture Extension Supervisor, local authorities involved in decisions on nutrition issues Community health worker, midwife, child health nurse

10–15 10 5

4. District level government

5. Health workers

Timing of surveys The baseline perception surveys were conducted between April 2014 and February 2015, and the end-line surveys between May and October 2016. As far as possible, the baseline perception surveys were carried out through integration into other planned surveys or activities to avoid creating an additional burden for the countries. For example, in Uganda and the United Republic of Tanzania, they were conducted in conjunction with district assessments, and in Ethiopia. they were carried out along with a pilot coverage survey and a surveillance gap assessment.

3 1 2

http://www.who.int/nutrition/landscape_analysis/country_assessment_methodology/en/ http://www.who.int/nutrition/landscape_analysis/country_assessments_summaries/en/ Questionnaires 1,2,4 and 5. Questionnaire 3, directed towards media, was not repeated as none of the countries implemented specific activities addressing media in the context of the ANI project.

Implementation of surveys in countries In all countries, the assessment team was led by national government staff and supported by WHO and partners. Country teams adapted the tools to suit the local health services and infrastructure as well as the public administrative realities, selected target respondents and sites, trained data collection teams, collected the data and performed country analyses and reporting. Many countries also presented the results at national stakeholder meetings.

Global level analyses Data from all countries were cleaned, harmonized and merged at the global level by WHO headquarters. Analyses included descriptive statistics and assessment of the four ANI PMF indicators, which were subsequently included in the ANI PMF baseline and end-line reports.

Assessment of the ANI PMF indicators Assessing the four perception indicators required creating algorithms for aggregating the rich perception survey datasets into one indicator value per country. PMF Intermediate outcome 1300: Awareness of the country’s nutrition situation Awareness of the country’s nutrition situation was assessed through open-ended questions to national and district level stakeholders. Responses were coded straightaway into previously defined categories related to nutrition problems and their immediate, underlying and basic causes. Perceptions related to the priority given to nutrition by the government were also assessed. This indicator was defined as the proportion of stakeholders surveyed who are aware of the nutrition situation, and had a target of 50% (WHO, 2014). The algorithm to estimate the indicator was defined as the proportion of stakeholders who mentioned more than half of the existing Global Nutrition Target-related nutrition problems in their country. In other words, awareness around any one Global Nutrition Target was only considered if this constituted a problem in the country. To determine whether a country had a Global Nutrition Target-related problem or not, data from the most recent national surveys available in countries were assessed against established cut-off values (for stunting, wasting and anaemia), cut-off values derived from the global target (overweight and exclusive breastfeeding), or those used in previous similar analyses (low birth weight) (Table 2 and Table 3). Individual responses were analysed to count the number of existing Global Nutrition Target-related problems mentioned in their countries, and the ANI PMF indicator was calculated as the proportion of stakeholders who mentioned more than half of these problems. PMF Immediate outcome 1120: Government capacity for nutrition surveillance The survey questionnaires explored various aspects of capacity for conducting nutrition surveillance at national, district and health facility levels. Information was gathered on data collection, flow between different levels, reporting and use in routine surveillance and in surveys. Respondents were also asked how they perceived and would rate government capacity to collect, analyse and report nutrition survey and routine data. This indicator was defined as the proportion of government respondents who have the capacity to do surveillance, and had a target of 70% (WHO, 2014). However, clearly not all individual government respondents at national and district levels need to have skills to collect and analyse nutrition data. Therefore, rather than focusing on individual capacity, the algorithm was defined as the proportion of high or very high ratings of government capacity to perform any of the aspects of nutrition surveillance.

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

Baseline

End-line

Baseline

End-line

Baseline

End-line

Baseline

End-line

Baseline

End-line

Baseline

End-line

Baseline

End-line

Baseline

End-line

Baseline

End-line

Baseline

Stunting 51.4% (2012) 18% (2010) 4.7% (2010) 33% (2012) 8.6% (2013) 11.5% (2016) 6.7% (2011) 6.7% (2011) 8.7% (2013) 5.8% (2014) 6.9% (2010) 4.7% (2014) 4.7% (2011) 33% (2012) 41% (2011) 41% (2011) 38% (2013) 33% (2015) 32% (2010) 58% (2014) 63% (2011) 63% (2011) 4.7% (2011) 4.7% (2010) 7.1% (2011) 7.1% (2011) 1.4% (2013) 0.3% (2016) 8.4% (2008) 7.5% (2013) 3.4% (2011) 3.4% (2011) 5% (2010) 50% (2010) 4.8% (2010) 16% (2012) 14% (2011) 14% (2011) 1.3% (2014) 1.3% (2014) 11% (2008) 7% (2013) 10.2% (2011) 10.2 % (2011) 7% (2010) 7% (2015) 4% (2015) 59% (2015) 4.5% (2015) 51.4% (2012) 52.4% (2011) 52.4% (2011) 54% (2013) 54% (2013) 45% (2008) 45% (2013) 23% (2011) 23% (2011) 40 % (2010) 45 % (2015)

31.5% (2013)

30.2% (2015)

44% (2011)

38.4% (2016)

27.5% (2013)

23.1% (2016)

43% (2011)

18.7% (2013)

19.4% (2014)

34.1% (2010)

28.8% (2014)

33.4% (2011)

34.0% (2011)

42% (2010)

34.0% (2015)

40% (2013) 29.2% (2011) 9% (2013) 1% (2013) 73% (2013) 6% (2013)

40.0% ZAM 29.2% (2011) 9% (2013) 1% (2013) 73% (2013) 6% (2013)

32% (2010–2011) 28% (2010–2011) 10% (2010–2011) 6% (2010–2011) 31% (2010–2011) 3% (2010–2011)

27% (2015) 27% (2015) 10% (2015) 6% (2015) 48% (2015) 3% (2015)

Anaemia

49.5% (2010)

61.9% (2014)

17% (2011)

23% (2016)

Low birth weight

10.3% (2013)

9.8% (2014)

11% (2011)

Overweight

2% (2014)

1% (2015)

1.7% (2011)

2.8% (2016)

Exclusive breastfeeding

47.2% (2013)

46.7% 2015)

52% (2011)

58% (2016)

Wasting

8.2% (2013)

10.4% (2015)

10% (2011)

9.9% (2016)

Data sources:

Burkina Faso: Stunting, overweight, wasting, exclusive breastfeeding from Standardized Monitoring and Assessment of Relief and Transitions (SMART) surveys 2013, 2104 and 2015; anaemia among women of reproductive age from Demographic and Health Survey (DHS – Enquête démographique et de santé (EDS)) 2010 and from Iodine and anaemia nutrition survey (Enquête nutritionnelle iode et anémie Burkina Faso (ENIAB)) 2014; low birth weight from annual statistic bulletin (annuaire statistique) 2013 and 2014.

Ethiopia: DHS 2011, DHS 2016.

Mali: Stunting, wasting from SMART surveys 2013 and 2016; anaemia among women of reproductive age and exclusive breastfeeding from DHS 2012; low birth weight from Multiple Indicator Cluster Survey (MICS) 2010 and DHS 2012; overweight from DHS 2010.

Mozambique: DHS 2011.

Senegal: Stunting, low birth weight, overweight, wasting from continuous DHS (EDS continue) 2013 and 2014 and ANI sentinel surveillance 2016; anaemia among women of reproductive age from National survey on food security and nutrition (Enquête nationale sur la sécurité alimentaire et la nutrition (ENSAN)) 2013; exclusive breastfeeding from continuous DHS (EDS continue) 2013 and 2015.

Sierra Leone: Stunting, exclusive breastfeeding and wasting from Sierra Leone Nutrition Survey (SLNS) 2010 and 2014; anaemia among women of reproductive age, low birth weight and overweight from DHS 2008 and 2013.

Uganda: DHS 2011 except for anaemia which is prevalence estimate for 2011 published by WHO (2015): The global prevalence of anaemia in 2011.

United Republic of Tanzania: DHS 2010, DHS 2015.

Zambia: DHS 2013.

Zimbabwe: DHS 2010-11, DHS 2015.

End-line

4 Mali Mozambique Senegal Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Table 2. Country data related to the 2025 Global Nutrition Targets: prevalence and year

Red colour indicates that the value is within the cut-off level used for indicating a nutrition problem.

Burkina Faso

Ethiopia

Table 3. Cut-off values used to determine country-relevant nutrition problems GLOBAL NUTRITION TARGET CUT-OFF VALUE USED SIGNIFICANCE/REASON REFERENCE

Stunting Anaemia Low birth weight Child overweight Exclusive breastfeeding Wasting

≥ 20% ≥ 20% ≥ 10% ≥ 7% < 50% ≥ 5%

Level of public health significance Moderate or severe problem Used in previous similar analyses Represents a higher rate than the global level baseline Represents a non-attainment of global target Unacceptable level

(WHO, 1995) (WHO, 2008) (WHO, 2013) (WHO, 2014) (WHO, 2014) (WHO, 1995)

PMF Immediate outcome 1220: Health workers’ capacity to deliver nutrition interventions To assess health workers’ capacity to deliver nutrition interventions in the three countries that were supported to scale up nutrition actions, the survey explored health workers’ knowledge of and confidence to deliver essential nutrition actions, their training and their perceived adequacy of time to provide nutrition services. This indicator was defined as the proportion of health workers surveyed who perceive that they have the knowledge to deliver nutrition services, and had a target of 75% (WHO, 2014). The algorithm for this indicator was set as the proportion of health workers who answered correctly a minimum of six out of eight knowledge questions, concerning the delivery of micronutrient supplementation to pregnant women, early initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding, HIV and breastfeeding, timely introduction of complementary feeding, hospital-based management of severe acute malnutrition (SAM), and promotion of healthy diets and lifestyles. PMF Intermediate outcome 1100: Health workers’ capacity and confidence to do nutrition surveillance Health workers’ capacity and confidence to do nutrition surveillance was assessed by their knowledge of and confidence around growth monitoring and anthropometry, their training and their perceived adequacy of time to conduct nutrition surveillance. This indicator was defined as the proportion of health workers who feel confident to do nutrition surveillance, and had a target of 50% (WHO, 2014). The algorithm for this indicator was set as the proportion of health workers who feel confident about most or every aspect of carrying out conventional nutrition surveillance activities, for example taking anthropometric measurements, plotting and interpreting growth charts, completing child health cards and analysing nutrition data.

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

III. Results

Responses A total of 767 baseline and 498 end-line interviews were conducted with stakeholders at national, district and facility levels (Table 4). Nine countries reached most of the recommended sample sizes described at baseline (three countries met all), whereas six countries met most of the recommended sample sizes at end-line (five countries met all). The higher number of interviews at baseline was mainly due to very large sample sizes among district officials and health workers in two countries (Uganda and Zambia); these were more than four times the recommended sample sizes.

Perception of the nutrition situation and priorities in countries Awareness of Global Nutrition Target-related problems in countries At baseline, four countries (Ethiopia, Mali, Mozambique and the United Republic of Tanzania) had already reached the target of 50% or more of respondents being aware of more than half of the relevant Global Nutrition Target-related problems in their countries, while at end-line this had increased to seven countries (Burkina Faso, Ethiopia, Mali, Senegal, Sierra Leone, the United Republic of Tanzania and Zambia) (Figure 1). Awareness more than doubled in three countries (Burkina Faso, Sierra Leone and Zambia), whereas in four countries (Mali, Mozambique, Uganda and Zimbabwe) there was a decrease in awareness of country-relevant problems. ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Stunting was perceived as a problem by a majority of respondents in all countries at both baseline and end-line (Figure 2), including in Senegal where national stunting rates were just below the 20% cut-off value for public health significance. Wasting was mentioned as a problem by a majority of respondents in most countries at both baseline and end-line. Exceptions were Uganda, the United Republic of Tanzania and Zimbabwe where the wasting rates were below the 5% cut-off value for acceptable prevalence. At end-line, a majority of respondents in four countries (Ethiopia, Sierra Leone, the United Republic of Tanzania and Zambia) reported anaemia as a key problem in their countries. Low birth weight and overweight were perceived as nutrition problems by fewer than 25% of respondents in most countries at baseline and in many countries at end-line. Anaemia, low birth weight, overweight and exclusive breastfeeding were perceived as problems more than twice as often at end-line compared to baseline in four countries (Burkina Faso, Ethiopia, Sierra Leone and Zambia). All respondent groups interviewed at both baseline and end-line (government, development practitioners and district level stakeholders) mentioned more problems related to the Global Nutrition Targets at end-line than baseline (Figure 3). Low birth weight, overweight and exclusive breastfeeding were mentioned more than twice as often by government and district officials at end-line than at baseline; mention of wasting remained stable. Media respondents, who were only interviewed at baseline, generally mentioned problems related to the Global Nutrition Targets less frequently than other respondents.

Table 4. Number of respondents by respondent group Green colour indicates that the recommended sample size was reached. 2. DEVELOPMENT PRACTITIONER 1. GOVERNMENT

4. DISTRICT

5. HEALTH WORKER

3. MEDIA

BASELINE Burkina Faso Ethiopia Mali Mozambique Senegal Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe Baseline subtotal END-LINE Burkina Faso Ethiopia Mali Mozambique Senegal Sierra Leone Uganda United Republic of Tanzania Zambia Zimbabwe End-line subtotal Grand Total 24 10 10 3 10 11 5 10 4 5 92 189 11 10 10 5 9 15 10 11 7 7 95 192 – – – – – – – – – – – 55 12 10 10 5 10 13 13 12 11 15 111 312 22 20 20 7 19 22 34 25 11 20 200 517 69 50 50 20 48 61 62 58 33 47 498 1 265 REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES 17 12 13 8 18 11 6 5 1 6 97 10 16 11 10 11 15 8 0 9 7 97 6 5 6 4 5 5 5 5 8 6 55 10 8 11 7 9 13 39 16 55 33 201 20 12 20 15 18 22 71 32 82 25 317 63 53 61 44 61 66 129 58 155 77 767

TOTAL

98%

97%

100%

Figure 1. Indicator 1300: Awareness of a majority of country-relevant problems related to the Global Nutrition Targets as perceived by respondents representing government at national and district level, development practitioners and media, by country (n= 450 at baseline, 298 at end-line) Baseline End-‐line

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

66%

54%

50%

62%

69%

46%

42%

40%

41%

47%

29%

Zambia Burkina Faso Ethiopia Mali (n=41; Mozambique Senegal Sierra Leone Uganda United (n=43; 47) (n=41; 30) 30) (n=29; 13) (n=43; 29) (n=44; 39) (n=58; 28) Republic of (n=73; 22) Tanzania (n=26; 33)

Zimbabwe (n=52; 27)

Awareness of nutrition problems and causes beyond the Global Nutrition Targets Among all respondents in all the countries, problems related to child undernutrition were most commonly mentioned, followed by vitamin and mineral deficiencies and by undernutrition among women (Figure 4). Whereas 96% of respondents mentioned child undernutrition as a problem in their countries, they generally referred to stunting and wasting. Only 19% specified low birth weight at baseline; this increased to 43% at end-line. Similarly, whereas more than 50% of respondents mentioned undernutrition among women as a problem in their countries, they generally referred to anaemia or underweight. Short stature in women was only mentioned by 6% of respondents at baseline, which increased to 18% at end-line. Reference to low birth weight, short stature among women, overweight in children and adults, iodine deficiency and vitamin A deficiency more than doubled between baseline and end-line. Perception of all main problem groups (child undernutrition, undernutrition among women, overweight and obesity, and vitamin and mineral deficiencies) increased in five countries (Burkina Faso, Ethiopia, Sierra Leone, the United Republic of Tanzania and Zambia) from baseline to endline (Figure 5). The proportions more than doubled for overweight and obesity in four countries (Burkina Faso, Ethiopia, Sierra Leone and Zambia), for undernutrition in women in three countries (Ethiopia, the United Republic of Tanzania and Zambia) and for vitamin and mineral deficiencies in two countries (Burkina Faso and Zambia). The most commonly mentioned causes of nutrition problems were food insecurity, lack of knowledge, inadequate infant and young child feeding (IYCF) and caring practices, disease burden, poverty and insufficient health services or unhealthy environments (Figure 6 and Figure 7). Perception of a causal relationship between nutrition problems and the lack of recommended breastfeeding practices, inadequate sanitation, inadequate hygiene, unclean water, increasing food prices, malaria and disasters increased by more than two-fold between baseline and end-line.

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

26%

Low birth weight 100% 97% 100% 95% 93% 90% 93% 88% 97% Overweight Exclusive breasReeding WasJng 100% 67% 58% 64% 54% 15% 15% 7% End-‐line Baseline End-‐line Zambia (n=73; 22) Baseline Zimbabwe (n=52; 27) End-‐line 19% 41% 27% 18% 10% 3% 17% 19% 15% 13% 31% 31% 38% 48% Baseline 16% 0% 42% 21% 33% End-‐line Senegal (n=43; 29) 100% 100% 100% 95% 100% 68% 67%

Figure 2. Problems related to the G lobal Nutrition argets as pTargets erceived as by perceived respondents representing government at national and district level, development Figure 2. Problems related to the Global T Nutrition by respondents representing government at national and district level, practitioners a nd media, by country (n= 450 at baseline, 298 at country end-‐line) (n= development practitioners and media, by 450 at baseline, 298 at end-line)

StunJng

Anaemia

98%

84%

94%

77%

79%

76%

73%

76% 69%

62%

45% 43%

40%

28%

27%

57% 47% 37%

17% 20%

27% 37%

32% 22% 15% 24%

21% 19% 12%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% End-‐line Mali (n=41; 30) 91% Baseline End-‐line 34% 41% 14% 28% Baseline Ethiopia (n=41; 30) Mozambique (n=29; 13) 15% 23% End-‐line 46% 58%

Baseline

End-‐line

Burkina Faso (n=43; 47)

95% 97%

84%

77%

72% 69%

68%

36%

41% 21% 17% 29%

10% End-‐line Baseline

0% Uganda (n=58; 28)

Baseline

9% 9%

20%

End-‐line

Baseline

Sierra Leone (n=44; 39)

11% 14% 18%

United Republic of Tanzania (n=26; 33)

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

38% 12% 15% 27% 42%

30%

27%

40%

32%

39% 39% 42% 55%

50%

41%

60%

57%

70%

64%

65%

80%

73%

90%

81%

100%

92%

12% 10% 5%

Baseline

92%

85%

83%

76%

62%

63% 74%

70% 49% 48% 36% 44%

14% 14% 19%

10% Baseline (n=97) 2. Development prac^onner 3. Media End-‐line (n=95) Baseline (n=55) Baseline (n=201) End-‐line (n=111) 4. District

Baseline (n=97)

End-‐line (n=92)

1. Government

9% 11% 11% 16%

20%

30% 18% 12% 17%

30%

36% 29% 21% 33%

38% 36% 30%

40%

37%

50%

59% 45% 54% 42%

44%

60%

80%

73%

75%

90%

80%

81%

100%

91%

97%

10 Low birth weight Overweight Exclusive breasaeeding Was^ng

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Figure 3. Problems related to the Global Nutrition Targets as perceived by respondents representing government Figure 3. Problems related to the Global Nutrition Targets as perceived representing at n ational and district level, development practitioners and media, by by respondents type of respondent (n= 450 at baseline, 298 government at national and district level, development practitioners and media, by type of respondent at end-‐line) (n= 450 at baseline, 298 at end-line)

Stun^ng

Anaemia

Awareness of nutrition problems and causes beyond the Global Nutrition Targets

Among all respondents in all the countries, problems related to child undernutrition were most commonly mentioned, followed by vitamin and mineral deficiencies and by undernutrition among women (Figure 4). Whereas 96% of respondents mentioned child undernutrition as a problem in their countries, they generally referred to stunting and wasting. Only 19% specified low birth weight at baseline; this increased to 43% at end-‐line. Similarly, whereas more than 50% of respondents mentioned undernutrition among women as a problem in their countries, they generally referred to anaemia or underweight. Short stature in women was only mentioned by 6% of respondents at baseline, which increased to 18% at end-‐line. Reference to low birth weight, short stature among women, overweight in children and adults, iodine deficiency and vitamin A deficiency more than doubled between baseline and end-‐line. Perception of all main problem groups (child undernutrition, undernutrition among women, overweight and obesity, and vitamin and mineral deficiencies) increased in five countries (Burkina Faso, Ethiopia, Sierra Leone, the United

Figure 4. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents representing government at national and district level, development practitioners and media (n= 450 at Figure 4. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as perceived by respondents baseline, 298 at end-line) Baseline 77% End-‐line 72%

representing government at national and district level, development practitioners and media (n= 450 at baseline, 298 at end-‐line)

71%

56%

52%

47%

44%

50%

43%

30%

24%

29%

21%

19%

18%

10%

20%

14%

19%

30%

24%

40%

39%

50%

42%

43%

60%

51%

59%

70%

68%

80%

72% 78%

90%

100%

96% 96%

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

100%

98%

100% 97%

80%

85%

98%

74%

100%

100% 79% 68% 91%

70%

61%

59% 66% 62%

54%

67%

49%

47%

44%

37%

26%

20%

47% 33%

10%

15%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline (n=53) Ethiopia Mali End-‐line (n=50) Baseline (n=61) End-‐line (n=50) Baseline (n=44) End-‐line (n=20) Mozambique 0%

Baseline (n=63)

End-‐line (n=69)

Baseline (n=61)

End-‐line (n=48) Senegal

Burkina Faso

95%

100% 100% 95% 100%

98%

100% 100%

100%

88%

97% 85%

90%

82%

94%

73%

69%

79%

61%

55%

53%

58%

79%

46%

34%

29%

42% 35% 50%

49%

20%

21% 34%

29% 25% 33%

81%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline (n=129) Uganda End-‐line (n=62) Baseline (n=58)

Baseline (n=66)

End-‐line (n=61)

End-‐line (n=58) United Republic of Tanzania

Baseline (n=155)

End-‐line (n=33) Zambia

Baseline (n=77)

End-‐line (n=47) Zimbabwe

Sierra Leone

22% 15% 30%

48% 48%

72%

12 UndernutriJon in women Overweight and obesity Vitamin and mineral deﬁciencies

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Figure 5. Problems related to child undernutrition, undernutrition in women, overweight and obesity, and vitamin and mineral deficiencies as Figure 5. Problems related to child undernutrition, undernutrition in women, overweight nd obesity, and vitamin and mineral deficiencies as pmedia, erceived by country respondents perceived by respondents representing government at national and a district level, development practitioners and by (n= representing g overnment a t n ational a nd d istrict l evel, d evelopment p ractitioners a nd m edia, b y c ountry ( n= 4 50 a t b aseline, 2 98 a t e nd-‐line) 450 at baseline, 298 at end-line)

Child undernutriJon

Figure 6. Causes of nutrition problems as perceived by respondents representing government at national and district level, development Figure 6. Causes of nutrition problems as perceived by respondents representing government at national and district level, development practitioners and media (n= practitioners and media (n= 450 at baseline, 298 at end-line) Baseline 70% 73% End-‐line 56% 65% 68% 76% 50% 53% 41% 50%

450 at baseline, 298 at end-‐line)

69% 76%

46%

42%

39%

36%

31%

29%

20%

21%

18%

17%

10%

20%

12%

16% 26%

16%

19%

30%

24%

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

30%

40%

32%

38%

50%

41%

46%

60%

52%

53%

61%

70%

63%

80%

72%

90%

86% 85%

100%

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

94% 85%

98%

81%

93% 83% 80% 100% 93%

83%

79%

71% 73%

60%

93% 67% 57% 70% 80%

59% 72% 59%

69%

77%

51% 49%

66% 62% 68% 55% 49%

63% 53%

56% 49%

51% 51% 61% 49% 51%

46%

39% 41%

34% 37%

33%

48% 38%

23%

22%

28%

54% 46% 46%

19%

88% 49% 53% 77% 70% 67%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline (n=53) Ethiopia 90% Mali End-‐line (n=50) Baseline (n=61) End-‐line (n=50) Baseline (n=44) End-‐line (n=20) Mozambique 100% 100% 100% 100% 100% 100% 15%

Baseline (n=63)

End-‐line (n=69)

Baseline (n=61)

End-‐line (n=48) Senegal

Burkina Faso

91%

88%

97% 95% 100% 97% 85% 95%

81%

88%

72%

69%

86% 69% 64% 78% 84% 71%

62%

68%

79%

61%

66% 59% 66%

82% 67% 58% 67%

61%

44%

41%

71% 36% 43% 57% 71% 61%

42%

31%

27% 27%

30%

26% 33% 37%

35%

65% 62%

19%

18%

11%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline (n=129) Uganda End-‐line (n=62) Baseline (n=58)

Baseline (n=66)

End-‐line (n=61)

End-‐line (n=58) United Republic of Tanzania

Baseline (n=155)

End-‐line (n=33) Zambia

Baseline (n=77)

13%

21%

Sierra Leone

Zimbabwe

33% 30% 22% 26% 37% 44% 30% End-‐line (n=47)

17%

97% 69% 55% 83% 76% 62%

14 Disease burden Lack of knowledge Poverty (lack of money) Insuﬃcient health services or unhealthy environment

7. Figure

Figure 7 . Causes of nutrition problems as perceived by respondents representing overnment at national and district level, development practitioners and media, by practitioners and media, by country (n= 450 at baseline, 298 at g end-line) country (n= 450 at baseline, 298 at end-‐line)

Causes of nutrition problems as perceived by respondents representing government at national and district level, development

Food insecurity

Inadequate caring and IYCF pracQces

Government priority for nutrition Commitment to nutrition requires both awareness and priority-setting. A higher proportion of respondents perceived that the government gave a “high” or “very high” priority to nutrition at end-line in three countries as compared to baseline in ten countries (Figure 8). More than half of the respondents in four countries (Burkina Faso, Mali, Senegal and Sierra Leone) indicated that Government priority for nutrition government made nutrition a “high” or “very high” priority (Figure 9).

). At baseline, healthtworkers in ten a countries assessed their“own commitment to nutrition At b10 aseline in ten countries, he perceptions bout government giving high” or “very high” priority to nhigher utrition were most common among government employees, whereas at end-‐line in tcountries hree countries similarly high rwas atings were also than that of the decision-makers, whereas at end-line in three their assessment more seen among health workers a). nd district officials (Figure 10). At baseline, health workers in ten countries assessed comparable (Figure 11 their own commitment to nutrition higher than that of the decision-‐makers, whereas at end-‐line in three countries their assessment was more comparable (Figure 11).

Commitment to nutrition requires both awareness and priority-‐setting. A higher proportion of respondents perceived that the overnment gave a perceptions “high” or “very high” priority to nutrition at end-‐line in three countries as At baseline in g ten countries, the about government giving “high” or “very high” priority compared to baseline in most ten countries (Figure 8). M ore than half o f the respondents in four ountries (in Burkina to nutrition were common among government employees, whereas at c end-line threeFaso, Mali, Senegal asimilarly nd Sierra high Leone) indicated that government made nutrition a “high” or “very high” priority (Figure 9). countries ratings were also seen among health workers and district officials (Figure

Figure 8. Government priority for nutrition as perceived by all respondents in ten and in Figure 8. Government priority for nutrition as p erceived by all respondents in ten countries at baseline countries at baseline and in three countries at end-line (n=767 at baseline, three countries at end-‐line (n=767 at baseline, 167 at end-‐line) 167 at end-line) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Baseline End-‐line 53% 34%

18%

24%

10%

0.60%

14%

25%

1. Very low

2. Low

3. Medium

4. High

5. Very high

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

51%

47% 32%

25%

26% 40% 26%

22%

39% 30% 21%

23%

71%

12% 28% 35%

21% 30% 25% 15% 9%

6% 13%

7% 18% 41% 25%

16% 9%

16% 11% Baseline (n=58) Baseline (n=155) Zambia

16% 22% 36%

3% 8% 38% 33% 18%

5% 5%

1% 1%

0% 8%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2. Low 3. Medium 4. High 5. Very high Baseline (n=61) Mali Mozambique Senegal Sierra Leone End-‐line (n=50) Baseline (n=44) Baseline (n=61) 0% 2% 4% End-‐line (n=48) 2% 14% 23% 36% 26% Baseline (n=66) Baseline (n=129) Uganda

0% 11% 35% 35% 19%

Baseline (n=63)

End-‐line (n=69)

Baseline (n=53)

Burkina Faso

Ethiopia

United Republic of Tanzania

5% 14% 38% 22% 21% Baseline (n=77) Zimbabwe

56%

44%

40%

30%

25% 36% 24%

14% 26%

14%

5% 10%

0% 2%

3% 10%

14% 6%

0% 6% 9%

10% 17% 34% 22% 17%

10% Baseline (n=97)

Baseline (n=97)

End-‐line (n=44)

End-‐line (n=30)

Baseline (n=55) 3. Media

Baseline (n=201)

End-‐line (n=32) 4. District

Baseline (n=317)

1. Government

2. Development pracXonner

5. Health worker

0% 0% 8%

20%

13%

14% 18% 33% 21% 14%

30%

20%

23%

28%

40%

End-‐line (n=61)

36%

50%

43%

60%

56%

70%

64%

16 2. Low 3. Medium 4. High 5. Very high

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Figure 9. 9. Government priority for nutrition as perceived by all respondents in ten countries at bcountries aseline and in three countries t end-‐line, by country (n=767 at baseline, Figure Government priority for nutrition as perceived by all respondents in ten at baseline and inathree countries at end-line, by 167 at end-‐line) country (n=767 at baseline, 167 at end-line)

1. Very low

Figure 10. Government priority for nutrition as perceived by all respondents in ten countries at countries baseline and three countries at end-‐line, by type f respondent Figure 10. Government priority for nutrition as perceived by all respondents in ten atin baseline and in three countries ato end-line, by (n=767 at baseline, 167 a t e nd-‐line) type of respondent (n=767 at baseline, 167 at end-line)

100%

90%

1. Very low

80%

Figure 11. Health workers’ perception of priority given to nutrition by decision-makers and by themselves in their daily work in ten countries at baseline and in Figure 11 Health workers’ perception of priority given to nutrition by decision-‐makers and by themselves in their three countries at end-line (n=317 at baseline, 61 at end-line) daily work in ten countries at baseline and in three countries at end-‐line (n=317 at baseline, 61 at end-‐line) 1. Very low 2. Low 3. Medium 4. High 5. Very high 100% 90% 80% 70% 11 Health workers’ perception of priority given to nutrition by decision-‐makers and by themselves in their Figure 60% daily work in ten countries at baseline and in three countries at end-‐line (n=317 at baseline, 61 at end-‐line) 50% 40% 1. Very low 2. Low 3. Medium 4. High 5. Very high 100% 30% 90% 20% 80% 10% 70% 0% 60% Baseline (n=317) End-‐line (n=61) Baseline (n=317) End-‐line (n=61) 56% 34% 36% 17% 22% 10% 17% 22% 29% 36% 56% 8%

Perception Baseline of nutrition surveillance (n=317) End-‐line (n=61) Government capacity for nutrition surveillance Government capacity for nutrition surveillance

50% 40% 30% 20% 10% 0%

34%

36%

17%

10%

17%

Decision makers make nutri^on a priority 8% 0% 0%

22%

Health workers make nutri^on a priority 10% 0% 0%

29%

36%

39%

51%

10%

39%

51%

Perception of nutrition surveillance Decision makers m ake nutri^on a priority

Baseline (n=317)

End-‐line (n=61)

Health workers make nutri^on a priority

by country (n=395 at baseline, 298 at end-‐line)

Figure 12. Indicator 1120: Perceived “high” or “very high” government capacity for nutrition surveillance as nutrition surveillance as reported by respondents representing government

Figure 12. Indicator 1120: Perceived “high” or “very high” government capacity for (n=395 at baseline, 298 at end-line)

at national and district level 100% by country (n=395 at baseline, 298 at end-‐line) 90% 80% 49% 60% 50% 40% 100% 70% 90% 80% 70% 60%

reported by respondents representing government at national and district level and development ractitioners, and development practitioners, bypcountry

Baseline End-‐line 55%

51%

48%

44%

43%

44%

41%

34%

33%

31%

36%

30%

49%

24%

27%

51%

48%

44%

43%

44%

55%

41%

19%

41%

13%

34%

33%

24%

27%

20% 40% 10% 30% 20% 0% 0% 10% Burkina Faso

30%

(n=37; 47)

Ethiopia Mali (n=35; Mozambique Senegal Sierra Leone Uganda United Zambia Zimbabwe (n=36; 30) 30) (n=25; 13) (n=38; 29) (n=39; 39) (n=53; 28) Republic of (n=65; 22) (n=46; 27) Tanzania Zambia Zimbabwe Burkina Faso Ethiopia Mali (n=35; Mozambique Senegal Sierra Leone Uganda United 33) 22) (n=46; 27) (n=37; 47) (n=36; 30) 30) (n=25; 13) (n=38; 29) (n=39; 39) (n=53; 28) Republic (n=21; of (n=65; Tanzania (n=21; 33)

13%

19%

31%

36%

30% 50%

41%

43%

Baseline End-‐line

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

(Figure 14). Overall, the capacity for undertaking surveys waso perceived than for performing in six countries (Burkina F aso, Mali, Senegal, Uganda, the United Republic f Tanzania ahigher nd Zambia); the full distribution w ithin e ach c ountry i s s hown i n F igure 1 3. G overnment s taff m ost o ften r ated t hemselves a s h aving routine data collection (Figure 15). “high” r “ very high” apacity for nutrition surveillance (Figure Overall, the capacity or n uutrition ndertaking surveys was Figure 1o 2. Indicator 1c 120: Perceived “high” or “very high” 1 g4). overnment capacity ffor surveillance as perceived higher than for prerforming routine data collection (Figure 1 5). district level and development practitioners, reported by respondents epresenting government at national a nd

No country achieved the ANI PMF target of 70% for this indicator (Figure 12). Small increases in rating were observed No country achieved the ANI PMF target of 70% for this indicator (Figure 12). Small increases in in six countries o (Burkina Faso, ali, Senegal, the United Republic of Tanzania and Zambia); the full Perception f nutrition sM urveillance Uganda, rating were observed in six countries (Burkina Faso, Mali, Senegal, Uganda, the United Republic of distribution within each country is shown in Figure 13. Government staff most often r ated themselves as having Tanzania and Zambia); the full distribution within each country is shown in Figure 13 . Government Government c apacity f or n utrition s urveillance “high” or “very high” capacity for nutrition surveillance (Figure 14). Overall, the capacity for undertaking surveys was staff most rated themselves as “high” or “very high” capacity for inutrition surveillance perceived higher than for p erforming routine d ata collection ( 1 5). No country aoften chieved the ANI PMF target o f 7having 0% f or this indicator (Figure Figure 1 2). Small increases n rating were observed

38%

36%

38% 34%

25% 29% 26%

23%

26% 31% 27%

26%

21% 29% 37%

20%

14% 23%

18%

11%

10%

0% End-‐line (n=30) Mali Baseline (n=35) End-‐line (n=30) Ethiopia

Baseline (n=37)

End-‐line (n=47)

0% 7%

Baseline (n=36)

Baseline (n=25)

End-‐line (n=13) Mozambique

Baseline (n=38)

End-‐line (n=29) Senegal

Burkina Faso

100%

90%

80% 45%

70% 37% 33% 35% 42% 23% 35% 29% 19% 32% 30% 20% 6% 7% 8% 11% 3% 9% End-‐line (n=33) United Republic of Tanzania Baseline (n=65) End-‐line (n=22) Zambia 3% 8% 6% Baseline (n=46) End-‐line (n=27) Zimbabwe 3% 13% 25% 18% 4% 15%

60%

45% 37%

13%

0% End-‐line (n=28) Uganda

Baseline (n=39)

End-‐line (n=39)

Baseline (n=53)

10%

11% 22% 37% 27%

20%

13%

Baseline (n=21)

Sierra Leone

20% 27% 34%

30%

23% 34% 34%

40%

40% 34%

50%

0% 7% 1% 4% 6%

10%

20%

13%

30%

21% 32% 37%

40%

33% 39%

45% 39%

50%

42% 44%

18 2. Low 3. Medium 4. High 5. Very high

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Figure 13. Government capacity for nutrition surveillance as perceived by respondents representing national and district level and Figure 13. Government capacity for nutrition surveillance as perceived by respondents representing g overnment at government national and dat istrict level and development development practitioners, by country (n=395 at baseline, 298 at end-line) practitioners, by country (n=395 at baseline, 298 at end-‐line)

1. Very low

100%

90%

80%

70%

60%

practitioners, by type oc f respondent (n=395 a t baseline, 2 at end-‐line) Figure 14. Government apacity for nutrition surveillance a98 s perceived by respondents representing government at national and district level and development practitioners, by type of respondent ( n=395 a t b aseline, 2 98 a t e nd-‐line) 1. Very low 2. Low 3. Medium 4. High 5. Very high 2. Low 3. Medium 4. High 5. Very high

Figure 14. Government capacity for nutrition surveillance as perceived by respondents representing government at national and district level and capacity for nutrition surveillance as perceived by respondents representing government at national and district level and development Figure 14. Government development practitioners, by type of respondent (n=395 at baseline, 298 at end-line)

1. Very low

38% 38%

32% 32%

28% 28%

29% 29%

34% 37%

34% 8% 8% 37% 8% 8%

22% 22%

17% 17%

6% 33% 33% 36% 36% 22% 22%

14% 14%

8% 24% 24% 37% 37% 23% 23%

8% 8%

100% 90% 100% 80% 90% 70% 80% 60% 70% 50% 60% 40% 50% 30% 40% 20% 30% 10% 20% 0% 10% 10% 10%

3% 3%

0% Baseline (n=97) End-‐line (n=95) 2. Development pracDonner 2. Development pracDonner

Baseline (n=97)

End-‐line (n=92)

Baseline (n=97)

End-‐line (n=95)

8% 8% 15% 15% 33% 33% 33% 33%

Baseline (n=201) Baseline (n=201)

End-‐line (n=111) End-‐line (n=111) 4. District 4. District

13%

Figure 15. Government capacity for various aspects of nutrition surveillance as perceived by respondents representing government at national and district level and Figure 15. Government capacity for various aspects of nutrition surveillance as perceived by respondents representing government at national Figure 15. Government capacity for a vt arious aspects a ot f e nnd-‐line) utrition surveillance as perceived by respondents representing government at national and district level and development practitioners (n=395 baseline,298 and district level and development practitioners (n=395 at baseline,298 at end-line) development practitioners (n=395 at baseline,298 at end-‐line) 2. Low 2. Low 3. Medium 3. Medium 4. High 4. High 5. Very high 5. Very high

Baseline (n=97) 1. Government End-‐line (n=92) 1. Government

1. Very low 1. Very low

8% 8%

11% 11% 13% 13% 39% 39% 28% 28%

12% 12% 17% 17% 42% 25% 42% 25%

7% 7% 23% 23% 36% 36% 26% 26% 8% 8%

7% 7% 22% 22% 35% 35% 28% 28%

8% 8%

4% 4%

100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% Baseline End-‐line Baseline End-‐line ReporDng ReporDng

Baseline End-‐line Baseline End-‐line Data collecDon Data collecDon

Baseline End-‐line Baseline End-‐line Baseline End-‐line Baseline End-‐line Data analysis Data ﬂow Data analysis Data ﬂow RouDne RouDne

6% 6% 25% 25% 35% 27% 35% 27% 9% 9% 10% 10% 14% 14% 37% 27% 37% 12% 27% 12% 7% 7% 28% 28% 34% 23% 34% 8% 23% 8% 16% 18% 16% 39% 18% 22% 39% 5% 22% 5% 6% 14% 6% 33% 14% 36% 33% 10% 36% 10% 1% 10% 1% 10% 34% 37% 34% 18% 37% 18% 6% 17% 6% 29% 17% 35% 13% 29% 35% 13% 2% 15% 2% 33% 15% 36% 33% 14% 36% 14% 9% 20% 9% 29% 20% 34% 29% 9% 34% 9% 3% 22% 3% 39% 22% 28% 39% 28% 8%

Baseline End-‐line Baseline End-‐line Baseline End-‐line Baseline End-‐line Baseline End-‐line Baseline End-‐line Data collecDon Data analysis ReporDng Data collecDon Data analysis ReporDng Survey Survey

24 24 REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

Nutrition data being collected At baseline, information was sought from government respondents, district officials and health workers regarding the type of nutrition indicators being measured in countries. More than 60% Nutrition data being collected of respondents reported collecting data on wasting and on low birth weight, while information on other Global Nutrition Targets were mentioned less frequently (Figure 16). w There marked At baseline, information was sought from government respondents, district officials and health orkers were regarding differences between countries, as illustrated in Figure 17 with respondents in some countries the type of nutrition indicators being measured in countries. More than 6,0% of respondents reported collecting data on wasting and on low birth weight, while information on other Global Nutrition were mentioned less reporting fewer indicators. Beyond the Global Nutrition TargetTargets indicators, many respondents frequently 16). Tdata here w ere marked differences between countries, as illustrated in Figure 17, with collected(Figure coverage on different micronutrient supplementation schemes. respondents in some countries reporting fewer indicators. Beyond the Global Nutrition Target indicators, many respondents collected coverage data on different micronutrient supplementation schemes. Figure 16.

Collection of data for Global Nutrition Target indicators as reported by government respondents at national and district level, and health workers Figure 16. Collection of data for Global Nutrition Target indicators as reported by government respondents at (n=615) national and district level, and health workers (n=615) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

48%

61%

41%

StunSng

Anaemia in women Anaemia in Low birth weight of reproducSve age pregnant women

25%

Overweight

28%

Exclusive breasWeeding

42%

WasSng

63%

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

Figure 17 portrait – m aybe pushing it a bit??? Landscape provided below Use of nutrition data StunSng

32% 22% 44% 61% 10% 20% 71%

36% 25% 29% 38% 23% 20% 41%

28% 26%

27%

18% 26%

Perception of health worker capacity for delivering nutrition services and 10% performing nutrition surveillance 0% Burkina Faso Ethiopia Mali n=44) Mozambique Sierra Leone Health workers’ capacity to (deliver nutritionSenegal interventions (n=47) (n=32) (n=30) (n=45) (n=46) Uganda (n=116)

20%

5% 0% 0% 15% 0% 10%

30%

18%

21%

23%

A majority of health workers in the three scale-up countries Republic of Tanzania) answered correctly on at least six out of eight knowledge questions at baseline (Figure 20). All three countries attained the ANI PMF target of 75%; Ethiopia had already reached this at baseline. Knowledge about the duration of continued breastfeeding increased by two thirds or more in Uganda and the United Republic of Tanzania, and knowledge about infant feeding recommendations for mothers with HIV increased by a similar proportion in Ethiopia (Figure 21). 25

United Zambia Zimbabwe Republic of (n=138) (n=64) (Ethiopia,Tanzania Uganda and the United (n=53)

24% 24%

26%

Nearly all media respondents claimed to be writing or speaking about nutrition (Figure 19). A 60% majority had received nutrition information from the government or partners, and most of them 50% perceived that the information they had received was adequate for media purposes. 40% 47% 42% 37% 47% 40% 44% 37% 41% 38% 41% 45% 40% 34%

52%

70%

56% 37% 49% 34% 49%

58% 57%

68% 60% 78%

68%

60% 67%

65%

Low birth weight Overweight breasWeeding At baseline, information was collected on the use of nutrition data.Exclusive A majority of government WasSng respondents at national and district levels described using data for reporting to government at national level as well as for revising their annual action plans (Figure 18). More than half of 100% government respondents at national level also mentioned using these data to report to donors and 90% 80% for advocacy. 79% 81% 91% 85% 82% 84% 90% 76% 69% 69% 76%

Anaemia in women of reproducSve age

Anaemia in pregnant women

Figure 17. Collection of 2025 Global Nutrition Target indicators as reported by government at national and district level, and health workers, by country (n=615) Anaemia in pregnant women Low birth weight Overweight Exclusive breasWeeding 90%

Figure 17. Collection of 2025 Global Nutrition Target indicators as reported by government at national and district level, and health workers, by country (n=615) WasSng 84% 79% 81% 91% 71% 76% 76% 78% 68% 52% 26% Zimbabwe (n=64) 34% 60%

StunSng

Anaemia in women of reproducSve age

82%

85%

65%

61%

68%

44%

47%

49%

60% 67%

41%

38%

42% 37%

56% 37% 49%

34%

44% 37%

41%

27% 47% 40%

69% 69%

36% 25% 29% 38%

32% 22%

21%

23%

18%

18% 26%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 10% 20% Mozambique (n=30) Senegal (n=45) Sierra Leone (n=46) Uganda (n=116) United Republic of Zambia (n=138) Tanzania (n=53) 23% 20% 24% 24% 28% 26% 58% 57% 41% 45% 40%

5% 0% 0% 15% 0% 10%

Burkina Faso (n=47)

Ethiopia (n=32)

Mali (n=44)

Figure 18. Uses of nutrition data collected as reported by government respondents at national and district level (n=298) Figure 18. Uses of nutrition data collected as reported by government respondents at national and district level (n=298) Government naSonal level Government district level 51% 45% 51% 52%

The three latter categories were only asked at district level.

The three latter categories were only asked at district level

100%

36%

23%

27%

30%

20%

10% Discuss behaviour Advocate for behaviour Use it for acSon, e.g. Feedback to the lower Revise the ministry/ Advocate for increased levels (e.g. regional, district annual acSon a[enSon to nutriSon change with mothers change in communiSes emergency response and caregivers district, health centre) plan among local decision makers

Report to government at the naSonal level

Report to donor organizaSons

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

21%

40%

31%

50%

41%

60%

54%

70%

67%

80%

75%

90%

centre)

local decision makers

caregivers

19. Perception of nutrition information as reported by media respondents Figure (n=55) 91%

Figure 19. Perception of nutrition information as reported by media respondents (n=55) 73%

Health workers’ capacity to deliver nutrition interventions 60%

70%

A majority of 50% health workers in the three scale-‐up countries (Ethiopia, Uganda and the United Republic of Tanzania) 40% on at least six out of eight knowledge questions at baseline (Figure 20). All three countries answered correctly 30% attained the A NI PMF target of 75%; Ethiopia had already reached this at baseline. Knowledge about the duration of 20% continued breastfeeding increased by two thirds or more in Uganda and the United Republic of Tanzania, and 10% infant feeding recommendations for mothers with HIV increased by a similar proportion in Ethiopia knowledge about (Figure 21). 0% Write or speak about nutriOon

Figure 20. Indicator 1220: Correct knowledge on at least six out of eight questions related to the delivery of nutrition s ervices mong health workers in t he three scale-‐up ountries, by c ountry (n=115 at baseline, 79 at end-‐ Figure 20. a Indicator 1220: Correct knowledge on at c least six out of eight questions related to the delivery of nutrition services among health workers in the line) three scale-up countries, by country (n=115 at baseline, 79 at end-line) 100%

Have received nutriOon informaOon

InformaOon received is adequate

60%

100% Perception of health worker capacity for delivering nutrition services and performing 90% nutrition s80% urveillance

70% 60%

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

50% 40% 30% 20% 10% 0% Ethiopia (n=12; 20) Uganda (n=71; 34) United Republic of Tanzania (n=32; 25)

63%

90% 80%

70%

88%

83%

85%

100%

Baseline End-‐line

22 28

99% 100%

Figure 21. Correct knowledge on delivery of various nutrition services, as reported health workers in the three scale-‐up countries, by country (n=115 at baseline, 79 at Figure 21. Correct knowledge on delivery of various nutrition services, as reported health workers in the three scale-up countries, by country end-‐line)

(n=115 at baseline, 79 at end-line)

94% 96%

97% 97% 94% 91% 94%

95% 100% 100% 100% 100% 95% 90% 100%

88%

83%

92% 100% 92% 83% 75% 83%

79%

74%

72%

90% 62% Early iniHaHon of breasMeeding 56% 56% 56%

70% 47% 41% ConHnued breasMeeding 28%

100% 100% 68% 96% 80% 92% 92% IntroducHon of complementary feeding Hospital-‐based treatment of SAM BreasMeeding in HIV End-‐line (n=25) Overweight and obesity

80%

50% 30%

40%

30%

42%

60%

82% 82%

88% 84%

100%

MulHple micronutrient supplementaHon to pregnant women

20%

Exclusive breasMeeding in infants <6 months with diarrhoea

10% Baseline (n=71) Uganda United Republic of Tanzania End-‐line (n=34) Baseline (n=32)

Baseline (n=12)

End-‐line (n=20)

Ethiopia

Could probably work in portrait as well? see below:

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

Health worker training two years. Few health workers had been trained in that period and virtually all of them expressed a Health worker training

The baseline survey assessed health workers’ training (pre-service or in-service) during the previous

The aseline s urvey a ssessed health w orkers’ training (pre-‐service or in-‐service) he previous two years. and Few or b severe acute malnutrition, followed by infant feeding, hygiene,during and t growth monitoring health workers had been trained in that period and virtually all of them expressed a need for more training. The promotion. Almost all health workers felt that the training they had received was relevant for their most common training topics reported were management of moderate or severe acute malnutrition, followed by nutrition tasks (Figure ). Having beenatrained in breastfeeding in the recent a smaller infant feeding, hygiene, and 22 growth monitoring nd promotion. Almost all health workers felt past that thad he training they effect on the knowledge of key infant and young child feeding interventions than on the had received was relevant for their nutrition tasks (Figure 22). H aving been trained in breastfeeding in confidence the recent past had a smaller effect on the knowledge of key i23 nfant and young child fwere eeding interventions than o n the to implement such interventions (Figure ). Similar results found regarding the effect of confidence t o i mplement s uch i nterventions ( Figure 2 3). S imilar r esults w ere f ound r egarding t he e ffect o f training training on the knowledge and confidence to manage SAM (Figure 24). on the knowledge and confidence to manage SAM (Figure 24). Figure 22. Training and perceived training needs among health workers in ten countries at baseline (n=317)

need for more training. The most common training topics reported were management of moderate

Figure 22. Training and perceived training needs among health workers in ten countries at baseline (n=317) 98% 29% 27% 26% 36% 18% 20% 25% 26% 14% 12% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 92%

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

18%

97%

87%

89%

84%

62%

60% 35% 34%

50%

40%

30%

20%

10% Counselling on exclusive breas:eeding Counselling on complementary feeding Counselling on HIV and infant feeding

Early ini4a4on of breas:eeding

Infant feeding Timely introduc4on Dura4on of con4nued Exclusive recommenda4ons of complementary breas:eeding breas:eeding in foods infants < 6 months in the context of HIV with diarrhoea

Knowledge (answered correctly to ques4ons on nutri44on interven4ons)

58%

Conﬁdence (conﬁdent about most or every aspect of nutri4on interven4ons)

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

58%

70%

68%

70%

71%

80%

76%

90%

84%

100%

92%

Figure 23. Health worker knowledge of and confidence to carry out IYCF interventions in ten countries at baseline, by breastfeeding training Figure 23. Health worker knowledge of and confidence to carry out IYCF interventions in ten countries at baseline, by breastfeeding training status (n=317) status (n=317) Trained Not trained

96%

Figure 24. Health worker knowledge of and confidence to treat SAM in ten countries at Figure 24. Health worker knowledge of and confidence to treat SAM in ten countries at baseline, by SAM baseline, by SAM management training status (n=317) management training status (n=317) 97% 94% 100% 90% 80% 70% 60% 40% 30% 20% 10% 0% Knowledge: Correct answer on hospital-‐ based treatment of SAM Conﬁdence: Conﬁdent about most or every aspect of SAM treatment 34% 50% Trained 80% Not trained

Health workers’ capacity and confidence to do nutrition surveillance

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

workers’ perceived confidence to implement the four nutrition surveillance activities Health investigated varied considerably (Figure 25). At baseline, countries (Mali, Mozambique, Senegal, Health w orkers’ capacity a nd confidence to do nfive utrition surveillance Sierra Leone and Uganda) had met the ANI PMF target of 50%, while at end-line this had increased Health workers’ perceived confidence to implement the four nutrition activities of investigated varie to seven countries (Burkina Faso, Mali, Mozambique, Senegal, Sierra Leone,surveillance the United Republic considerably (Figure 2 5). At b aseline, five countries (Mali, Mozambique, Senegal, Sierra L eone and Uganda) ha Tanzania and Zimbabwe). Health workers recently trained in nutrition surveillance expressed higher the ANI PMF target of 50%, while at end-‐line this had increased to seven countries (Burkina Faso, Mali, Mozam levels of confidence to perform nutrition surveillance (Figure 26) as well as knowledge about WHO Senegal, Sierra Leone, the United Republic of Tanzania and Zimbabwe). Health workers recently trained in nutr Child Growth Standards (Figure 27). surveillance expressed higher levels of confidence to perform nutrition surveillance (Figure 26) as well as know about WHO Child Growth Standards (Figure 27).

Figure 25. Indicator 1100: Confidence in most or every aspect of implementing four nutrition surveillance activities as perceived by health workers in ten Figure 25. Indicator 1100: Confidence in most or every aspect of implementing four nutrition surveillance activities countries, by country (n=317) as perceived by health workers in ten countries, by country (n=317) Baseline End-‐line 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 78% 70% 71% 77% 82% 68% 85% 56% 41% 32% 37% 0% Zimbabwe (n=25; 20) 48%

67%

50%

38%

45%

Burkina Faso Ethiopia (n=20; 22) (n=12; 20)

Zambia Mali Mozambique Senegal Sierra Leone Uganda United (n=20; 20) (n=15; 7) (n=18; 19) (n=22; 22) (n=71; 34) Republic of (n=82; 11) Tanzania (n=32; 25)

50%

63%

Figure 26. Confidence in implementing four nutrition surveillance activities as perceived by health workers in ten countries, by nutrition surveillance training status (n=317)

43%

33%

25%

34%

38%

100% 90% 80% 70% 60% 50% 40% 30%

78%

76%

64%

68%

Not trained Trained

83%

87%

100%

56%

50%

58%

Figure 26. Confidence in implementing four nutrition surveillance activities as Figure 26 perceived by health workers in ten countries, by nutrition surveillance training status (n=317) 100% Trained Not trained 68% 58% 34% Zimbabwe (n=25) 38% 87%

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

78%

83%

64%

56%

76%

43%

33%

25%

43%

Burkina Faso (n=20)

Ethiopia (n=12)

Mali (n=20) Mozambique (n=15)

Senegal (n=18)

Sierra Leone (n=22)

Uganda (n=71)

United Republic of Tanzania (n=32)

Zambia (n=82)

50%

Figure 27. Health worker knowledge about WHO Growth Standards in ten countries, Figure 27 by nutrition surveillance training status (n=317) 100% 95% 100% 100% Trained 86% Not trained 75% 68% 69% 89% 83%

Burkina Faso (n=20)

Ethiopia (n=12)

Mali (n=20) Mozambique (n=15)

Senegal (n=18)

Sierra Leone (n=22)

Uganda (n=71)

United Republic of Tanzania (n=32)

Zambia (n=82)

Zimbabwe (n=25)

Summary of survey results Assessment of the ANI PMF perception indicators shows a high degree of achievement of those project targets on awareness of the nutrition situation, delivery of nutrition services and confidence of health workers to perform nutrition surveillance (Table 5). Many of the countries had already achieved certain project targets at baseline, and continued improving throughout the project period. On the other hand, based on the indicator definition and algorithm used, no country achieved the project target for perceived government capacity for undertaking nutrition surveillance.

REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

79%

78%

79%

61%

60%

64%

60%

33%

71%

Table 5. Summary of baseline and end-line values for ANI PMF perception indicators Green colour indicates achievement of target value. Indicator 1220 is only applicable in three scaling-up countries. 1300 % WHO MENTION A MAJORITY OF EXISTING PROBLEMS TARGET VALUE = 50% 1120 % WHO PERCEIVE GOVERNMENT CAPACITY FOR ANY ASPECT OF NUTRITION SURVEILLANCE AS HIGH OR VERY HIGH TARGET VALUE = 70% 1220 % HEALTH WORKERS WHO ANSWER AT LEAST 6 OUT OF 8 KNOWLEDGE QUESTIONS CORRECTLY TARGET VALUE = 75% 1100 % HEALTH WORKERS WHO FEEL CONFIDENT ABOUT MOST OR EVERY ASPECT OF THE FOUR ASPECTS OF NUTRITION SURVEILLANCE TARGET VALUE = 50%

Baseline Burkina Faso Ethiopia Mali Mozambique Senegal Sierra Leone Uganda United Republic of Tanzania ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI) Zambia Zimbabwe 40 54 54 66 42 41 41 69 47 29

End-line 98 97 50 46 62 97 29 97 100 26

Baseline 49 34 33 30 43 43 13 31 41 55

End-line 51 24 44 27 48 41 19 36 44 43

Baseline – 83 – – – – 70 63 – –

End-line – 100 – – – – 85 88 – –

Baseline 38 0 70 67 78 77 68 41 37 48

End-line 50 45 50 71 63 82 32 56 0 85

IV. Discussion and conclusion

The ANI project intensified action around nutrition surveillance in 11 sub-Saharan African countries and supported the scaling-up of interventions in three, with a particular focus on building capacity for nutrition surveillance and service delivery. The results of the perception surveys show that positive outcomes can be attained in a short but intense project period. The greatest successes were among health workers. Specific examples are described in more detail in the ANI Best Practices series (WHO, 2016). The lack of improvement in the indicator on government capacity for implementing nutrition surveillance may be due to limitations in the methodology, which used respondents’ perceptions as a proxy, rather than measuring the government’s actual ability. Low awareness of the nutrition situation in some countries could be linked to the fact that certain nutrition problems had not yet been set as national priorities. This could explain, for example, why stunting and wasting were more familiar issues than low birth weight and overweight. The lack of achievement of some project targets could also be linked to weakness in the methodology, such as having interviewed different individuals and in some instances observing large differences in sample sizes at baseline and end-line. This report highlights the motivation of health workers to acquire knowledge and skills in service delivery and surveillance. Nearly all respondents from across the ten countries reported that training was relevant to their work, and requested more. While having been trained or not in a specific nutrition area within the previous two years did not affect correct answers to the knowledge questions, it should be noted that these questions did not go into great depth on any specific nutrition topic. Thus, earlier training may still have had an effect on the health workers’ knowledge. The perception surveys provide an interesting and sizable data set that may be useful for other partners. For example, these data show the need to improve awareness of nutrition problems among media personnel. Furthermore, organizations working in these countries could benefit from the findings to guide the delivery of nutrition interventions. REPORT OF THE BASELINE AND END-LINE PERCEPTION SURVEYS IN TEN COUNTRIES

V. References

WHO (1995) Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. Technical Report Series No. 854. Geneva: World Health Organization. http://whqlibdoc.who.int/trs/WHO_TRS_854.pdf. WHO (2008) Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva: World Health Organization. http://www.who.int/vmnis/indicators/haemoglobin.pdf. WHO (2013) Global nutrition policy review. What does it take to scale up nutrition action? Geneva: World Health Organization. www.who.int/nutrition/publications/policies/global_nut_policyreview/en/ WHO (2014) ANI M&E Guideline and Methods. Geneva: World Health Organization. WHO (2016) Accelerating Nutrition Improvements: best practices for scaling up. Examples from Ethiopia, Uganda and the United Republic of Tanzania. Geneva: World Health Organization. http://who.int/nutrition/publications/ANI-bestpractices-scalingup/en/.

ACCELERATING NUTRITION IMPROVEMENTS IN SUB-SAHARAN AFRICA (ANI)

For further information please contact: Nutrition Policy and Scientific Advice Unit (NPU) Department of Nutrition for Health and Development (NHD) World Health Organization (WHO) 20, Avenue Appia CH–1211 Geneva 27 Switzerland Fax: +41.22.791.4156 E-mail: NPUinfo@who.int NHD website: http://www.who.int/nutrition

ISBN 978-92-4-151208-4

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 30 mars 2017

Source Organisation mondiale de la santé