SIXTY-FIFTH WORLD HEALTH ASSEMBLY Provisional agenda item 13.3
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Nutrition Maternal, infant and young child nutrition: draft comprehensive implementation plan Report by the Secretariat CORRIGENDUM
Please replace paragraph 25 of the Annex with the following text:
25. Global target 3: 30% reduction of low birth weight by 2025. The target implies a relative reduction of 30% of the number of infants born with a weight lower than 2500 grams by the year 2025, compared to a baseline set in 2006–2010 and used as a reference starting point. This would translate into a 3.9% relative reduction per year between 2012 and 2025. In Bangladesh and India, where around half the world’s children with low birth weight are born, the prevalence of low birth weight decreased, respectively from 30.0% to 21.6% (between 1998 and 2006) and from 30.4% to 28.0% (between 1999 and 2005). Reduction in the prevalence of low birth weight has been observed in El Salvador (from 13% to 7% between 1998 and 2003), South Africa (15.1% to 9.9% from 1998 to 2003), and the United Republic of Tanzania (from 13.0% to 9.5% between 1999 and 2005). In these examples, the recorded reductions are in the order of 1% to 12% per year. The higher reduction rates have been observed in countries where a large proportion of the low birth weight is accounted for by intrauterine growth restriction, which is more amenable to reduction than pre-term birth.
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SIXT TY-FIFTH WORLD W HEA ALTH ASS SEMBLY Prov visional age enda item 13.3
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Nutrit tion Matern nal, infan nt and yo oung child nutriti ion: draft compreh c hensive im mplementation pl lan Repo ort by the Secretariat S t
1. At the 130t th session of f the Executiv ve Board in January 2012, the draft i implementati ion plan was s ia, the Direc discu ussed.1 In dec cision EB130 0(2), inter ali ctor-General was requeste ed to conduc ct, as soon as s possible, further r consultatio ons regardin ng the targ gets within the existin ng draft com mprehensive e imple ementation plan p via a web-based w p process open n to all Mem mber States, as well as multilateral l organ nizations, to provide fur rther guidanc ce in the fin nalization of f the compre ehensive imp plementation n plan. This consu ultation was held 6–27 F February 2012.2 The dra aft plan refle ects the outc come of the e consu ultation (see Annex). In May 201 2. 10, the Healt th Assembly y in resolution n WHA63.23 on infant a and young ch hild nutrition n reque ested the Dir rector-Genera al “to develo op a compreh hensive implementation p plan on infan nt and young g child nutrition as a critical com mponent of a global multisectoral nutrition frame ework”. In Ja anuary 2011, , the E Executive Bo oard noted th he preparato ory work on such a plan n, making se everal suggestions on its s conte ent, including revising its name to cover mater rnal nutrition n and payin ng more atte ention to the e le burden of doubl f undernutriti ion and over rweight.3 In May M 2011 th he Health As ssembly note ed the report t on the subject and d the revised d outline of th he plan.4 3. In the cou urse of 2011, five region nal consulta ations to collect feedbac ck on the ou utline of the e comp prehensive implementati ion plan we ere convene ed in the African A Regi ion, the Region of the e Amer ricas, and the South-East t Asian, East tern Mediter rranean and Western Pac cific regions. . Altogether, , the co onsultations were attende ed by represe entatives of different gov vernment sec ctors (health, , agriculture, , socia al welfare, education, e trade, t financ ce, environm ment and in ndustry) fro om 92 Mem mber States, , organ nizations in the t United Nations system m, developm ment banks, donors and civ ivil society.
See docume ent EB130/10 an nd the summary y records of the e second and nin nth meetings in n document EB130 0/2012/REC/2. Comments were w received by b ten Member States and six multilateral m org ganizations. The e background paper and the summa ary of the comm ments received and the respons ses provided by y the Secretariat are available a at http://w www.who.int/n nutrition/events/ /2012_consulta ation_proposed_ _globaltargets/e en/index.html (a arch 2012). accessed 21 Ma 3 4 2
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See docume ents EB128/18 and a EB128/201 11/REC/2, summ mary record of the tenth meetiing.
See the sum mmary record of f the fourth mee eting of Commi ittee B, section 5 of the Sixty-f fourth World Health H Assem mbly.
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4. The a annexed dra aft implemen ntation plan integrates all a comments s provided b by Member States during meet tings of WHO’s governin ng bodies an nd the regiona al consultatio ons. It brings s together relevant elements from the glob bal strategy for f infant an nd young-chi ild feeding,1 the Global Strategy on n Diet, 2 Physical Ac ctivity and Health, H and th he action pla an for the glo obal strategy for the prev vention and control 3 of noncomm municable diseases. d WH HO’s framew work for pri iority action n for HIV an nd infant feeding, issued in 20 003, has been n recently up pdated to ref flect the revised WHO gu uidelines for r the prevent tion of mother-to-c child transmission of HIV V.4 5. Sever ral related regional r stra ategies and plans have been consid dered in pre eparing this draft comprehens sive plan: the e African Un nion’s Revise ed African Regional R Nutritional Strat tegy (2005–2 2015), the Second European Action A Plan for f Food and d Nutrition Policy (2007– –2012),5 the Strategy and d Plan of Action fo or the Reduc ction of Chro onic Malnutr rition,6 the Regional R strategy on nutr rition 2010–2 2019,7 the regional l nutrition str rategy for So outh-East As sia8 and the Framework F for f Action on n Food Security in 9 the Pacific. 6. The draft compr rehensive im mplementatio on plan sets out its rationale, nam mely the fact t that, worldwide, nutrition challenges are multifaceted d, effective nutrition n actio ons exist but t are not expanded sufficiently, , and that ne ew initiatives s have been launched. Th he plan defin nes its object tives and set ts five global targe ets and a tim me frame. It further f propo oses a series s of five high h-priority ac ctions for Me ember States, the S Secretariat an nd internatio onal partners, , and lists eff ffective health h interventio ons and non-health activities th hat affect nutr rition as well l as indicator rs for monito oring the imp plementation n of the plan.
New initia atives in nu utrition 7. The o optimal strategy to ensur re rapid impr rovement of nutrition req quires the im mplementatio on of a set of specif fic nutrition interventions and the inte egration of nutrition n into health, agric culture, educ cation, employmen nt, social we elfare and development d programme es. The Scal ling Up Nut trition move ement, launched in n 2010, has brought toge ether govern nment author rities from countries c wit th high burd den of malnutrition n and a glob bal coalition of partners. It calls for intensive i eff forts to scale e up nutrition n over the period 2 2013–2015 th hrough such h a strategy. P Partners in the t movemen nt have comm mmitted themselves to work tog gether to mo obilize resources, provide e technical support, s perf form high-le evel advocac cy and develop inn novative partn nerships.
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Endo orsed in 2002 by y the Health As ssembly in reso olution WHA55 5.25. Endo orsed in 2004 by y the Health As ssembly in reso olution WHA57 7.17. Endo orsed in 2008 by y the Health As ssembly in reso olution WHA61.14.
Antir retroviral drugs s for treating pregnant p women n and preventin ng HIV infectio on in infants: re ecommendation ns for a public health approach – 20 010 version. Geneva, G World H Health Organiz zation, 2010; WHO, W UNAIDS S, UNFPA, UN NICEF. Guidelines on HIV and infan nt feeding. 2010 0. Principles an nd recommenda ations for infant feeding in the e context of HIV V and a summary of ev vidence. Geneva a, World Health h Organization, , 2010. 5 6 7 8
Adop pted in 2007 by y the Regional Committee C for E Europe in resolution EUR/RC5 57/R4. Endo orsed in 2010 by y PAHO’s Dire ecting Council i in resolution CD D50.R11. Endo orsed in 2010 by y the Regional Committee for the Eastern Me editerranean in resolution EM//RC57/R.4.
Endo orsement by Me ember States of f this strategy w was urged in 201 11 by the Regio onal Committee e for South-East t Asia in resolution S SEA/RC64/R4. 9 The P Pacific Islands Forum Secretar riat reported the e endorsement of the action plan by the Pacif fic Food Summi it 2010 (Port Vila, Van anuatu, 21–23 April A 2010), see http://www.for rumsec.org/pag ges.cfm/newsroo om/press-statem ments/2010/fina aloutcomes-of-f food-summit-1.h html (accessed 27 March 2012 2).
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8. In order to o respond to the challen nges to succe essful coordination, orga anizations in n the United d Natio ons system have h commit tted themselv ves to better r align their activities at global level through the e reform m of the Un nited Nation ns Standing Committee on Nutrition and at co ountry level through the e Renewed Efforts against Child Hunger an nd Undernutr rition (REAC CH) initiative e. 9. ive for the elimination e o of new HIV infections in n children an nd improvin ng the health h The initiati and s survival of HIV-infected H d mothers1 su upports the improvemen nt of the nutr tritional state e of mothers s and th heir children n. 10. At regiona al level, a successful s e example of partnership is the Pan American Alliance A for r Nutri ition and Development for f the Achie evement of the t Millenniu um Developm ment Goals, launched in n 2009. 11. The draft comprehensiv c ve implemen ntation plan contributes c to o the global initiatives by y identifying g globa al targets and d priority acti ions in the h health sector and defining g roles for con oncerned part ties. Specific c discu ussions have been organiz zed with this s purpose.
IMP PLEMENTA ATION OF O THE IN NTERNAT TIONAL CODE C OF F MARKETING OF F BRE EAST-MILK SUBSTI ITUTES 12. In response e to the requ uirement for biennial rep porting,2 this report also provides inf formation on n progr ress made by y countries in the implem mentation of f the Internat tional Code of Marketin ng of Breastmilk Substitutes. The compre ehensive imp plementation n plan also covers c this a area and proposes future e activi ities. 13. The implem mentation of f the Internat tional Code of o Marketing g of Breast-m milk Substitu utes, adopted d by th he Health Assembly A in n resolution WHA34.22, and of su ubsequent re elated Health h Assembly y resolu utions is not t consistent among coun ntries. Statutory regulati ions have be een put in place p in 103 3 Mem mber States an nd have been n drafted in nine. Some 37 Member States rely o on voluntary y compliance e by in nfant formula a manufactu urers and 25 Member Sta ates have no ot taken actio on to enforc ce the Code; ; inform mation is missing for 20 Member Sta ates.3 14. Among th he Member States with legislation, , most have e provisions s on the prohibition of f prom motion of desi ignated prod ducts to the g general public c and health workers and d in health-ca are facilities, , as w well as prov visions on labelling re equirements. . Fewer Member State es have provisions on n conta amination wa arnings, and bans on nutr rition and hea alth claims. 15. Less than 50% of cou untries with legal meas sures also ha ave legal pr rovisions on n monitoring g imple ementation of o the Code e. Only 37 countries have h establis shed function oning monito oring and/or r enfor rcement mechanisms, and d limited inf formation on n the composition, manda ate and funct tions of such h mech hanisms is av vailable.
Global plan n towards the el limination of ne ew HIV infections among child dren by 2015 an nd keeping their r mothers alive, , 2011– –2015. Geneva, UNAIDS, 2011. Article 11.7 7 of the International Code; inf formation is col llected periodically from Mem mber States by questionnaire, q the latest surveys of the t status of imp plementation be eing issued in 2008 2 and 2010. 3 Information n from UNICEF F; these countrie es also include all Member Sta ates that reporte ed on Code imp plementation, uired under Cod de Articles 11.6 6 and 11.7. Que estionnaires wer re sent to Member States in 20 007 and 2009 an nd the results as requ were s summarized in documents d A61 1/17 Add.1, sec ction F, and A63 3/9. 2
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16. Inform mation on im mplementatio on of the Cod de is also pro ovided by reg gional office es, in collabo oration with partne ers in government an nd the Unit ted Nations system. A recent PA AHO review w on implementa ation of the Code C in the period p 1981– –2011 indica ates that 16 countries ha ave legal mea asures and six of th hem regulate e the implem mentation of t the law.1 In 2007 2 a review w by UNICE EF of 24 We est and Central Afr rican countri ies reported that half th hose countri ies had com mprehensive l legal measu ures in place.2 17. An an nalysis by th he Secretaria at of nutritio on policies in n Member States in 201 03 highlighte ed the following challenges: le egislation can n only be ap pplied in pub blic health facilities, does s not provide e clear operational guidance, is poorly enforced e and d inadequat tely monitor red; health workers ar re not adequately t trained; and the public is s not adequat tely informed d.
ACTION BY THE HEALTH H ASSEMBLY A Y 18. The H Health Assem mbly is invite ed to endorse e the compre ehensive imp plementation n plan on mat ternal, infant and y young child nutrition. n
1 30 añ ños del Código en América La atina: Un recorr rido sobre diver rsas experiencia as de aplicación n del Código Internacional d de Comercialización de Suced dáneos de la Lec che Materna en n la Región entre 1981 y 2011. Washington DC, D PAHO, 2011.
Soko ol E, Aguayo V, Clark D. Prote ecting breastfee eding in West and a Central Africa: 25 years im mplementing the International C Code of Market ting of Breast-m milk Substitutes s. Dakar, UNICEF Regional Office for West a and Central Afr rica, 2007. See h http://www.who o.int/nutrition/E EB128_18_Bac ckgroundpaper1 1_A_review_of_ _nutritionpoliciies.pdf (accesse ed 27 March 2012 2). 3
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ANNE EX DR RAFT COM MPREHEN NSIVE IMP PLEMENT TATION PL LAN ON M MATERNA AL, INFAN NT AND YO OUNG CHI ILD NUTR RITION
RAT TIONALE Glob bal nutritio on challenge es are mult tifaceted 1. Adequate provision p of f nutrients, b beginning in n early stage es of life, is s crucial to ensure good d physi ical and men ntal developm ment and lon ng-term healt th. Poor avail lability or ac ccess to food d of adequate e nutrit tional quality y or the expo osure to cond ditions that impair i absor rption and us se of nutrien nts has led to o large sections of the t world’s population p b being underno ourished, hav ving poor vit itamin and mineral m status s or be eing overweig ght and obes se, with large e differences s among pop pulation grou ups. These co onditions are e often n present simu ultaneously and a are inter rconnected. 2. In women, , both low body b mass i index and sh hort stature are highly p prevalent in low-income e count tries, leading g to poor fet tal developm ment, increas sed risk of complication c ns in pregnan ncy, and the e need for assisted delivery.1 In n some coun ntries in sou uth-central Asia, more th han 10% of women w aged d 15–49 9 years are shorter than n 145 cm. In n sub-Sahara an Africa, so outh-central and south-e eastern Asia, , more than 20% of o women ha ave a body m mass index le ess than 18.5 5 kg/m2 and this figure is i as high as s 40% in Banglade esh, Eritrea and a India. Co onversely, an n increased proportion p of f women star rt pregnancy y with a body mass s index greater than 30 kg g/m,2 leading g to increased risk of com mplications in i pregnancy y and d delivery as well w as heavie er birth weigh ht and increa ased risk of obesity o in chi ildren. 3. Iron-deficie ency anaemi ia affects 30 0% women of reproduct tive age (46 68 million), and 42% of f pregn nant women (56 million). Maternal an naemia is associated with h reduced bir irth weight an nd increased d risk o of maternal mortality. m An naemia rates have not imp proved appre eciably over the past two decades.2 4. Every year r an estimate ed 13 million n children ar re born with h intrauterine e growth restriction3 and d 4 about t 20 million n with low birth b weight. A child bo orn with low w birth weig ght has a gre eater risk of f morb bidity and mortality m and d is also mo ore likely to o develop noncommuni n icable diseas ses, such as s diabe etes and hype ertension, lat ter in life. 5. In 2010 about 115 million children worldwide were w underw weight, 55 mi illion had low w weight for r 5 their height and 171 million n under the age of five years had stunted grow wth. The pr roportion of f childr ren under th he age of fiv ve years in d developing countries c wh ho were unde erweight is estimated to o 1 Black RE et t al. Maternal an nd Child Under rnutrition Study y Group. Matern nal and child un ndernutrition: global g and region nal exposures an nd health consequences. Lance et, 2008; 371:24 43-260. Data ar re also taken fro om the Monitor ring and Evalua ation to Assess and Use Result ts Demographic c and Health Su urveys (MEASU URE DHS) proj oject (http:// /www.measuredhs.com/Data/, , accessed 27 M March 2012). 2 United Nations System Sta anding Committ tee on Nutrition n. Progress in nutrition: n Sixth report on the world w nutrition situati ion. Geneva, Un nited Nations System Standing g Committee on n Nutrition Secr retariat, 2010.
de Onis M, Blössner M, Vi illar J. Levels a and patterns of intrauterine i growth retardation n in developing countries. f Clinical Nutrit tion, 1998; 52(S Suppl.1):S5-S15 5. European Journal of United Nati ions Children’s s Fund and Wo orld Health Org ganization, Low w birthweight: country, regional and global l ates. New York, United Nation ns Children’s Fu und, 2004. estima 5 4
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lth Statistics 20 Underweigh ht and stunting, in: World Heal 010, Geneva, World W Health Or rganization, 201 10.
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have declin ned from 29% % to 18% between 1990 0 and 2010, a rate that is i still inade equate to me eet the Millennium m Developme ent Goal 1, Target 1.C of halving levels of un nderweight b between 1990 and 2015. Suffic cient decline e took place in i Asia and L Latin Americ ca, but considerable effor rts are still needed n in Africa. In n addition, in i 2010, 43 million m presc chool children in develo oping and de eveloped cou untries were overw weight or obe ese.1 The prevalence of c childhood obesity in low- and middle e-income cou untries has been ac ccelerating in n the past 10 years; WHO O estimates that t in 2015 the rate will l reach 11%, , close to the prevalence in up pper-middle-income coun untries (12%) ). Obese chi ildren are lik kely to grow w into obese adult ts; have an increased i risk of type 2 diabetes, liv ver disease and a sleep-ass sociated brea athing disorders; a and have dim minished chan nces of socia al and econom mic performa ance in adult t life. 6. Anae emia affects 47.4% (293 3 million ch hildren) of th he preschool-age popula ation,2 and 33.3% 3 3 (190 million n) of the pres school-age population p gl obally is def ficient in vita amin A. 7. Nutri itional status s is also infl luenced by s several envir ronmental fa actors. In co ountries where the prevalence of HIV infec ction is high, , HIV infecti ion has both a direct imp pact on the nu utritional sta atus of women and d children who w are infec cted and an indirect effe ect through alterations i in household d food security and inappropri iate choices of infant-fe feeding pract tices in orde er to preven nt mother-to o-child transmission n of HIV. Poor P food sec curity also i increases risk k-taking beh haviour by w women that places p them at inc creased risk of becoming g infected w with HIV. To obacco use (both ( smokin ng and smok keless tobacco) du uring pregnan ncy adversely y affects feta al health. Dir rect materna al smoking as s well as exp posure to second-h hand smoke during pregn nancy increa ases the risk of complica ations in pre egnancy, incl luding low birth w weight and preterm birt th. More pe eople are sm moking in many m low- t to middle-in ncome countries, in n particular young y girls and a women o of reproductive age. Altho ough the pro oportion of women w smoking is low in man ny countries, women and d their offspring still fac ce substantia al risks of ad dverse pregnancy outcomes because of th heir exposur re to second d-hand smok ke. Use of t tobacco tran nsmits tobacco co ontaminants to the fetu us through t the placenta a and to ne eonates thro ough breast milk. Expenditure e on tobacco o also limits s the capacit ty of familie es to provide e better nutri rition for pre egnant women and d children. 8. Child dhood malnu utrition is th he underlying g cause of death in an estimated 3 35% of all deaths d among child dren under th he age of five years. Mor re than two million m childr ren die each year as a res sult of undernutriti ion before th he age of five e years and i iron-deficien ncy anaemia is estimated d to contribut te to a significant n number of maternal m deat ths every yea ar in low- an nd middle-in ncome countr ries. Materna al and child undern nutrition acc count for 11% % of the glob bal burden of f disease.4 9. Maln nutrition has s a negative e impact on n cognitive developme ent, school performance e and productivity y. Stunting and iodine e and iron deficiencies s, combined d with inad dequate cog gnitive stimulation, , are leading g risk factors contributing g to the failu ure of an esti imated 200 m million child dren to attain their full develop pment poten ntial. Each 1 1% increase in adult he eight is asso ociated with a 4%
de Onis M, Bloessn ner M, Borghi E. E Global preval lence and trends of overweight t and obesity am mong preschool l children. Am J Clin Nutr 2010;92:1257–64. 2 De B Benoist B, McLe ean E, Egli I, Cogswell C M (Ed ds). Worldwide prevalence p of anaemia a 1993–2 2005: WHO glo obal database on an naemia. Genev va, World Health Organization n, 2008, pp.1–40 0. 3 Glob bal prevalence of o vitamin A def ficiency in popu ulations at risk 1995–2005: WHO W global data abase on vitami in A deficiency. Ge eneva, World Health H Organizat tion, 2009.
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Black k RE et al. Mat ternal and Child d Undernutrition n Study Group. . Maternal and child c undernutr rition: global an nd regional expos sures and health h consequences s. Lancet. 2008; ; 371:243-260.
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increa ase in agricu ultural wages1 and elimi inating anaem mia would lead to an in ncrease of 5% % to 17% in n adult productivity y. Malnutrit tion is an im mpediment to the progr ress towards s achieving Millennium m Deve elopment Go oals 1 (Eradicate extre eme poverty y and hunge er), 2 (Ach hieve univer rsal primary y educa ation), 3 (Pro omote gende er equality an nd empower women), 4 (Reduce ( chil ld mortality), 5 (Improve e mater rnal health) and a 6 (Comb bat HIV/AID DS, malaria an nd other dise eases).
Effec ctive nutrit tion actions s exist but a are not imp plemented on a suffici iently large e scale 10. A review and a policy analysis a of M Member Stat tes in 2009– –20102 indica ated that mo ost countries s have a range of policies p and programmes p on nutrition n. However, such policies s are often in nadequate in n face of the comp plexity of th he challenges s of materna al, infant an nd young chi ild nutrition n and do not t produ uce the expec cted impact. 11. Even when n nutrition policies exist, , they have not n always been b officiall ly adopted, often do not t articu ulate operati ional plans and program mmes of wo ork with clear goals and d targets, tim melines and d delive erables; they y do not spe ecify roles an nd responsib bilities for th hose involved d, or identif fy workforce e and c capacity need ds; and they do d not includ de process an nd outcome evaluation. e 12. The policy y review ind dicated that correcting maternal un ndernutrition n was not a priority in n count tries with a high h burden of o maternal m mortality. Fe ew of the 36 countries wi ith the greate est burden of f under rnutrition im mplement on a national s scale the ful ll set of effe ective interv ventions to prevent p child d under rweight and maternal und dernutrition a and to foster r early child development d t. 13. Interventio ons that can be managed d directly by y the health sector lack detailed imp plementation n guida ance and are e only partia ally impleme ented where health syste ems are wea ak. Many countries have e at incorpora adopt ted integrate ed strategies s for mater rnal, newbor rn and child d health tha ate nutrition n interv ventions, but t the actual delivery d of nu utrition supp port in health services is o often inadequ uate and few w indica ators are ava ailable to mea asure the cov verage. 14. National de evelopment strategies do o not give due d considera ation to nutr rition. Nation nal food and d nutrit tion policies often focus on informat tion and info formed-choice models an nd give little attention to o struct tural, fiscal and a regulator ry actions aim med at chang ging unfavou urable food e environments s. 15. Programme e implement tation is not well coordin nated among different ac ctors. In all regions r most t coord dination and administration of policie es occurred within w health h ministries, with variable input from m minis stries of edu ucation, agric culture, food d and welfar re. Policy an nd programm me implemen ntation often n depen nds on extern nal funding and a is not sus stainable. Monitoring of activities is either not regularly done e or is p poorly done. . 16. The implem mentation of the Intern national Cod de of Market ting of Brea ast-milk Sub bstitutes and d subse equent related Health Assembly r resolutions is not cons sistent amon ng countries. Statutory y regul lations have been put in n place in 10 03 Member States and have h been dr drafted in 9; 37 Member r
Haddad L, Bouis B HE. The impact i of nutrit tional status on n agricultural productivity: wa age evidence fro om the Philipp pines. Warwick k (United Kingd dom of Great B Britain and Nort thern Ireland), Development D E Economics Rese earch Centre. Papers s, No. 97, 1989. . See http://w www.who.int/nu utrition/EB128_ _18_Backgroun ndpaper1_A_rev view_of_nutritiionpolicies.pdf (accessed 27 Ma arch 2012). 2
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States rely o on voluntary y compliance e by infant fo ormula manu ufacturers, an nd 25 Memb ber States hav ve not taken action n to enforce the t Code; inf formation is missing for 20 Member States.1 17. In mo ost of those 103 Member States, th he legislation n makes pro ovisions for t the prohibiti ion of promotion o of designated d products to o the general public and health h worke ers and in hea alth-care faci ilities, and sets lab belling requi irements. Fe ewer Membe er States hav ve provisions on contam mination warnings, and bans on n nutrition an nd health clai ims. 18. Less than 50% of o countries with legal measures also a have leg gal provision ns on monitoring implementa ation of the Code. Only y 37 of thos se countries have establ lished functi ioning monitoring and/or enfo orcement mec chanisms, an nd limited in nformation on the compo osition, mand date and fun nctions of such mec chanisms is available. a 19. Regio onal offices continue to update the i information on implementation of th he Code. A recent r PAHO review on imple ementation over o the peri iod 1981–20112 indicated d that 16 co ountries have e legal measures a and six of th hem regulate e the implem mentation of f the relevan nt law. In a review in 2007, 3 UNICEF fo ound that, of o 24 West and Centra al African countries, c half h had com mprehensive legal measures in n place.
OBJECTI IVE, TARG GETS AND D TIME FR RAME 20. The p plan aims to o alleviate the t double b burden of malnutrition m in i children, starting from the earliest stag ges of devel lopment. Substantial ben nefits can be obtained by b concentra ating efforts from ut at the sam conception through the first two yea ars of life, bu me time a life e-course app proach needs s to be considered so that good nutritional status s can be maintained. 21. Progr ress can be made m in the short term, an nd most nutr rition challen nges can be re esolved with hin the current generation. For example, cu urrently avail lable nutritio on interventions should b be able to av vert at 4 least one thi ird of the cas ses of stuntin ng in the sho ort term. However, full elimination e o of some cond ditions may require e a longer time t frame and a commitm ment for a decade d of in nvestment to o expand nutrition intervention ns should be made, with the aim of a averting one million child deaths per r year. Takin ng into account the e need to alig gn the imple ementation o of the plan to o other development fram meworks tha at also consider nu utrition, it is proposed tha at this plan h has a 13-yea ar time frame e (2012–202 25). Reportin ng will nnially until 2022 and th be done bien he last report will be done e in 2025. al targets ar 22. Globa re important to identify priority areas and to ca atalyse globa al change. Global G targets may y inspire choi ices of priori ities and amb bitions establ lished at cou untry level. T They are not meant to dictate th he choices of o individual countries a and regions. . Global targ gets may be e used to me easure Infor rmation from UNICEF; U these countries also include all Me ember States tha at reported on iimplementation n of the Code, as requ uired its Article es 11.6 and 11.7 7. Questionnair res were sent to Member Stat tes in 2007 and d 2009 and the results were summari ized in documen nts A61/17 Add d.1, section F, a and A63/9. 2 Soko ol E, Aguayo V, Clark D. Prote ecting breastfee eding in West and a Central Africa: 25 years im mplementing the International C Code of Market ting of Breast-m milk Substitutes s. Dakar, UNICEF Regional Office for West a and Central Afr rica, 2007. 1
30 añ ños del Código en América La atina: Un recorr rido sobre diver rsas experiencia as de aplicación n del Código Internacional d de Comercialización de Suced dáneos de la Lec che Materna en n la Región entre 1981 y 2011. Washington DC, D PAHO, 2011. Bhut tta ZA et al. for the Maternal and a Child Under rnutrition Study y Group. What works? Interve entions for mate ernal and child unde ernutrition and survival. Lance et, 2008, 371:41 17-440. 4
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achie evements and d to develop p accountabil lity framewo orks. Targets s are needed d for nutrition conditions s that a are responsib ble for a large burden o of nutrition-r related morbidity and mo ortality from m conception n throu ugh the first t two years s of life: st tunting, ma aternal anaem mia and low w birth weight.1 Child d under rweight – of f which stun nting represe ents the large est fraction – is the larg gest cause of f deaths and d disab bility-adjusted d life years in i children u under the age e of five year rs, and iron d deficiency co ontributes to o mater rnal mortali ity in low- and middle e-income co ountries. Suc ch targets w would comp plement and d under rpin Target 1.C of Millennium Dev velopment Goal G 1 in relation to redu ducing the pr revalence of f under rweight child dren. Under that Goal, a fourth targ get on childh hood overwe eight is warr ranted, given n the ra apid increas se observed globally in the prevalen nce of that condition. c T The proposed d targets are e based d on country experiences and the exis stence of effe ective interve entions. 23. Global tar rget 1: 40% % reduction n of the glo obal number r of childre en under fiv ve who are e stunt ted by 2025. . This target implies a rel lative reduct tion of 40% of the numbe er of childre en stunted by y the y year 2025, co ompared to the baseline of 2010. This would tran nslate into a 3.9% relativ ve reduction n per y year between n 2012 and 20252 and implies redu ucing the nu umber of stu unted children from the e 171 m million in 20 010 to appro oximately 10 00 million, i. .e. approxim mately 25 mil llion less tha an what this s numb ber would be e if current trends t are no ot changed.3 An analysis of 110 coun ntries for wh hich stunting g preva alence is ava ailable on at least l two occ casions in th he 1995–2010 0 period4 rev veals that glo obal stunting g is dro opping at the e rate of 1.8% % per year ( (2.6% in cou untries with prevalence p h higher than 30%). 3 In this s period 20% of the e countries have h reduced stunting at a rate of 3.9 % or higher. 24. Global tar rget 2: 50% % reduction of anaemia in women of reproduc ctive age by y 2025. This s target t implies a relative r reduc ction of 50% % of the num mber of non-p pregnant wom men of repro oductive age e (15–4 49 years) af ffected by anaemia a by the year 20 025, compar red to a bas seline set in n the period d 1993– –2005 and used u as a refe erence startin ng point. Th his would translate into a 5.3% relativ ve reduction n per y year between 2012 and 20 025 and impl lies reducing g the number r of anaemic non-pregnan nt women to o appro oximately 23 30 million. Several count tries have de emonstrated a reduction i in anaemia prevalence p in n non-p pregnant women, as indicated by re epeated natio onal surveys reported in the Sixth re eport on the e world d nutrition si ituation of th he United Na ations Standi ing Committee on Nutriti ion:5 China from f 50% to o 19.9% % in 21 year rs (1981–2002); Nepal f from 65% to o 34% in 8 years (1998– –2006); Sri Lanka from m 59.8% % to 31.9% in 13 years (1988–2001 ); Cambodia a from 56.2% % to 44.4% in 6 years (2 2000–2006); ; Viet N Nam from 40% to 24.3% % in 14 years s (1987–2001 1); and Guatemala from 3 35% to 20.2% in 7 years s (1995 5–2002). The ese estimates s point to a 4 4% to 8% relative reduction per year. 25. Global tar rget 3: 30% % reduction of low birth h weight by y 2025. The target implies a relative e reduc ction of 40% % of the num mber of infan nts born wit th a weight lower than 2 2500 grams by the year r 2025, compared to a baseline set in 200 06–2010 and d used as a reference r sta arting point. This would d transl late into a 3.9% 3 relative e reduction p per year betw ween 2012 and a 2025. In n Bangladesh and India, , where e around half the world’s children w with low bir rth weight ar re born, the prevalence of low birth h weigh ht decreased d, respectivel ly from 30.0 0% to 21.6% % (between 1998 and 20 006) and fro om 30.4% to o The develop pment of global l targets has bee en requested by y Member States during region nal consultation n. Draft targets have b been discussed at a the regional consultations c in n the Region of f the Americas and a the Eastern Mediterranean n Region but broade er discussion with Member Sta ates is required at the Executiv ve Board and through electroniic consultation. 2 3 1
r = ln(P1/P P2)/t.
de Onis M, Bloessner M, Borghi B E. Preva alence and trend ds of stunting am mong pre-schoo ol children, 199 90–2020. Public c Health Nutriti ion, 2012, 15:14 42–148. 4 5
Obtained fro om 430 data po oints. United Nations Standing Committee C on N Nutrition. Sixth report r on the world w nutrition s situation. Genev va, 2010.
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28.0% (betw ween 1999 and a 2005). Reduction R in the prevalen nce of low birth weight h has been obs served in El Salvad dor (from 13 3% to 7% bet tween 1998 and 2003), South S Africa (15.1% to 9 9.9% from 19 998 to 2003), and the United Republic R of Tanzania (fr rom 13.0% to 9.5% betw ween 1999 an nd 2005). In n these examples, th he recorded reductions are a in the ord der of 1% to o 12% per ye ear. The high her reduction n rates have been o observed in countries c wh here a large p proportion of o the low bir rth weight is s accounted for by intrauterine growth restr riction, whic ch is more am menable to re eduction than n pre-term bi irth. 26. Glob bal target 4: No increas se in childho ood overwe eight by 202 25. The targe et implies th hat the global prevalence of 6.7 7% (95% co onfidence int terval (CI) 5.6–7.7) estim mated for 20 10 should no ot rise to 10.8% (in n 2025) as per p current trends1 and th hat the number of overwe eight children n under five years should not i increase from m 43 million n to approxim mately 70 million m as it could c be fore ecast. The ra ates of increase are e variable in n different pa arts of the w world, with more m rapid increases i in countries th hat are rapidly expa anding their food system ms, such as in n North Afric ca. In higher income coun ntries national and regional lev vel informat tion indicate e that highe er socioecon nomic group ps have a l lower increa ase in childhood o obesity. Lifes style and env vironmental intervention ns used in su uch circumsta ances can be e used as an examp ple of good practice. In low- and mi iddle-income e countries little program mmatic exper rience exists. Prog grammes aim med at curbin ng childhood d obesity hav ve mainly tar rgeted schoo ol age children.2 It would also o be importa ant to preve ent an incre ease in chil ldhood over rweight in c countries tha at are addressing t the reduction n of stunting. 27. Glob bal target 5: Increase ex xclusive brea astfeeding rates in the first f six mon nths up to at t least 50% by 20 025. This targ get implies that t the curre ent global av verage, estim mated to be 3 37% for the period p 2006–2010, , should incr rease to 50% by 2025. Th his would inv volve a 2.3% % relative incr crease per yea ar and would lead to approxim mately 10 mil llion more ch hildren being g exclusively y breastfed u until six mon nths of age. Globa ally, exclusiv ve breastfeeding rates i increased from 14% in 1985 to 3 8% in 1995 5, but decreased s subsequently y in most regions. r How wever, rapid d and substantial increa ases in exclusive breastfeedin ng rates, oft ten exceedin ng the propo osed global target, have e been achie eved in indiv vidual countries in n all regions, , such as Ca ambodia (fro om 12% to 60% 6 between n 2000 and 2 2005), Mali (from 8% to 38% between 199 96 and 2006) ) and Peru (fr from 33% to 64% betwee en 1992 and 2 2007). 28. Glob bal target 6: Reducing and a maintai ining childhood wasting g to less tha an 5%. This target should be reduced implies that t the global prevalence p of childhood w wasting of 8.6% 8 estimate ed for 2010 s to less than n 5% by 202 25 and maint tained below w such levels s.3 In the pe eriod 2005–2 2010, 53 cou untries reported ch hildhood wasting w rates s above 5% % at least once. Was sting reduct tion require es the implementa ation of prev ventive inter rventions su uch as impro oved access to high-qua ality foods and a to health care e; improved d nutrition and a health knowledge and practic ces; promot tion of exclusive breastfeedin ng for the fir rst six month hs and promo otion of impr roved comple ementary fee eding practic ces for all children n aged 6–24 months; and d improved w water and sa anitation syst tems and hy ygiene practices to protect child dren against communicab ble diseases. Large numb bers of childr ren with seve ere wasting can c be treated in t their commu unities witho out being ad dmitted to a health faci ility or a th herapeutic fe eeding
1 de O Onis M, Bloess sner M, Borghi i E. Global pre evalence and tr rends of overw weight and obe esity among pre eschool children. Amer rican Journal of Clinical Nutr rition, 2010, 92: :1257–1264. 2 Popu ulation-based prevention p strat tegies for child dhood obesity: : report of a WHO W forum an nd technical meeting, m Geneva, 15–17 7 December 20 009.
WHO O global and regional trend est timates for child d malnutrition, see http://www w.who.int/nutgro rowthdb/ estimates/en/in ndex.html (acce essed 23 April 2012). 2
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centre e.1 For mode erate acute malnutrition, m t treatment sh hould be base ed on optima al use of loca ally available e food, , complemen nted when necessary by sp pecially form mulated supp plementary fo oods.
ACT TIONS 29. This action n plan illustr rates a serie s of priority y actions tha at should be jointly impl lemented by y Mem mber States an nd international partners. . Specific reg gional and co ountry adapt tation will be e needed, led d by the relevant na ational and re egional instit tutions. ACT environmen TION 1: To o create a supportive s e nt for the im mplementati tion of comp prehensive food d and nutrit tion policies 30. Progress to owards nutrition goals r requires hig gh-level policy commitm ment and br road societal l suppo ort. Existing food and nu utrition polic cies need to be reviewed d so that they y comprehen nsively meet t all m main nutrition n challenges and a deal with th the distribu ution of thos se problems w within society. A further r aim o of such review is to ensur re that nutriti ion is placed d centrally in other sector ral policies an nd in overall l devel lopment poli icy. Crucial factors f for th he successful l implementa ation of these e policies are e: (a) official l adopt tion by rele evant govern nmental bod dies; (b) the e establishm ment of an i intersectoral governance e mech hanism; (c) the engage ement of d development partners; and a (d) the e involveme ent of local l comm munities. Th he private sector may a also contribute to a be etter food su upply and to t increased d emplo oyment and d therefore in ncome. Ade equate safeg guards to pre event potent tial conflicts s of interest t shoul ld be put in place. p 31. Proposed activities a for r Member S States (a) revis se nutrition policies so that they comprehensiv c vely address s the double e burden of f malnutritio on with a hum man rights-b based approa ach and an official endor rsement of parliament p or r governmen nt; (b) inclu ude nutrition in the count try’s overall developmen nt policy, Pov verty Reduct tion Strategy y ies; Papers and d relevant sec ctoral strategi (c) estab blish effectiv ve intersecto oral governan nce mechanisms for imp plementation of nutrition n policies at national n and local levels that contribu ute towards policy p integr ration across sectors; (d) enga age local gov vernments a and commun nities in the design of pl lans to expa and nutrition n actions and d ensure their r integration in existing community c programmes; p ; (e) estab blish a dialo ogue with re levant nation nal and international pa arties and form alliances s adequate me and partner rships to exp pand nutritio on actions wi ith the establ lishment of a echanisms to o safeguard against a poten ntial conflicts s of interest.
1 Community y-based management of severe acute malnutrition. A Joint St tatement by the World Health Organization, the Wo orld Food Programme, the United Nations Sy ystem Standing Committee on Nutrition and tthe United Nations Children’s Fund. WHO, Geneva a, 2007.
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32.
Prop posed activities for the Secretariat S (a) provide sup pport to Mem mber States, on request, in i strengthen ning national l nutrition po olicies and strategies, and nutritio on compone ents of oth her sectoral policies in ncluding na ational devel lopment poli icies and Pov verty Reducti ion Strategy Papers; (b) improve ac ccess to norm mative and po olicy guideli ines, knowledge products s, tools and expert e netwo orks.
33.
Prop posed activities for inter rnational par rtners (a) implement global advocacy initiat ncrease publ lic awarenes ss of the ne eed to tives that in expan nd actions on n nutrition; (b) strengthen international cooperation n on nutrition n in order to harmonize s standards, po olicies and a actions throu ugh adequate mechanism ms and inter rgovernmental bodies, su uch as the World W Healt th Assembly y, the Comm mittee on Wo orld Food Se ecurity and the t United N Nations Econ nomic and S Social Counc cil; (c) engage in international l coordinatio on mechanisms or partne erships, inclu luding the Scaling Up N Nutrition mov vement and the t United N Nations System m Standing Committee C o on Nutrition.
ACTION 2: To include all required effective e health inte erventions with w an imp pact on nutrition in nationa al nutrition plans p 34. Many y diverse int terventions aimed a at cha anging beha aviours, prov viding nutrit tional suppor rt and reducing th he exposure to several environmenta e al risk facto ors have bee en shown to o be effectiv ve and should be c considered for f impleme entation at n national scal le. Tables 1a a and 1b lis st effective direct nutrition in nterventions and health intervention ns that have an impact on nutrition n and that can c be delivered by y the health system. The lists includ de interventi ions that nee ed to be con nsidered eith her for selected po opulation gro oups or in special circ cumstances, including emergencies. e . Analysis of o the evidence is summarized d in a backg ground paper r to this plan n1 and repor rted in the W WHO e-Libra ary of Evidence fo for Nutrition n Actions2. WHO’s W guid deline process ensures that t evidenc ce is continu uously updated and d that gaps in n research ar re identified. . Such interv ventions are intended as options that could be impleme ented on the basis b of coun ntry needs. 35. The g greatest bene efits result fr rom improvin ng nutrition in the early stages s of life e. However, a lifecourse appr roach to imp proving nutr rition is also o needed, with activities s targeting o older childre en and , in order to adolescents besides infa ants and you ung children, o ensure the best possible e environme ent for mothers be efore concep ption so as to reduce th he incidence e of low bi irth weight and to brea ak the
Esse ential nutrition actions. Impro oving maternal l-newborn-infant and young child health an nd nutrition. Geneva, G World Health Organization, 2011. 2 2
1
http:/ //www.who.int/ /elena/en/ (acce essed 27 March h 2012).
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interg generational cycle of malnutrition. m Managemen nt of childho ood overwei ight would also require e 1 action n throughout t the school years. y 36. Interventio ons should be e integrated i into existing g health-care systems to t the extent po ossible. They y shoul ld be linked d to existing g programm mes and delivered as packages, in order to im mprove cost t effici iency. Imple ementation of o WHO’s a approaches and a interven ntions – Inte egrated Man nagement of f Child dhood Illnes ss, Integrate ed Managem ment of Adolescent A and a Adult Illness and d Integrated d Mana agement of Pregnancy and Childbi irth – will be b essential. Furthermor re, strengthe ening health h system ms forms a central c eleme ent of a succe essful nutriti ion strategy. 37. The design n of packag ges of interv vention can be based on o country needs and the t level of f inves stment. Com mmunity-base ed programm mes that inte egrate different direct nu nutrition inte erventions in n prima ary care, wit th systems to o ensure univ versal access s, should be prioritized p as s being cost-effective. A group p of organiz zations in the t United N Nations sys stem has joi intly produc ced the Uni ited Nations s OneH Health Costin ng Tool – sof ftware that c can easily be adapted to different d coun ntry contexts s.2 38. Proposed activities a for r Member S States interventions (a) inclu ude all prove en nutrition i s relevant fo or the countr ry in materna al, child and d adolescent health servic ces and ensu ure universal access; (b) refle ect the Globa al Strategy o on Infant and d Young Chi ild Nutrition n, the Global Strategy on n Diet and Ph hysical Activ vity and the W WHO nutriti ion guideline es in national l policies; (c) stren ngthen health h systems, p promote univ versal covera age and prin nciples of pri imary health h care; elop or whe ere necessary y strengthen n legislative e, regulatory y and/or oth her effective e (d) deve measures to control the e marketing of breast-mi ilk substitute es in order to o ensure imp plementation n of the Inte ernational Code C of Mar rketing of Breast-milk B Substitutes S a and relevant t resolutions s adopted by y the Health Assembly; A (e) 39. enga age in vigoro ous campaign ns to promote e breastfeedi ing at the loc cal level.
Proposed activities a for r the Secreta ariat (a) revie ew, update and a expand W WHO’s guid dance on and tools for eff ffective nutri ition actions, , highlight good g practice of delivery mechanisms s and dissemi inate the info ormation; (b) apply y cost-effect tiveness analy lysis to health h interventio ons with an im mpact on nut trition;
(c) prov vide support to t Member S States, on request, in imp plementing p policies and programmes s aimed at im mproving nut tritional outc comes;
1 Population-based prevent tion strategies f for childhood obesity: repor rt of a WHO fforum and tech hnical meeting, , Genev va, 15–17 Decem mber 2009. Gen neva, World He ealth Organizat tion, 2010.
http://www. .internationalhe ealthpartnership p.net/CMS_files s/userfiles/OneH Health%20leafl flet%20May2011.pdf (accessed 27 March 2012). 2
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(d) provide su upport to Member State es, on reque est, in their efforts to d develop or where neces ssary strength hen and mon nitor legislat tive, regulato ory and other r effective m measures to control mark keting of brea ast-milk subs stitutes; (e) 40. convene a meeting m with h academic p partners to de evelop a prio oritized resea arch agenda.
posed activities for inter rnational par rtners Prop (a) align plans for developm ment assistan nce to nutriti ion actions re ecognized as s effective;
(b) support the e nutrition co omponents o of health stra ategies for maternal m and child health h, such as the e Integrated Maternal M Ne ewborn and C Child Health Strategy. ACTION 3: To stimu ulate develop pment polic cies and prog grammes ou utside the he ealth sector that recognize and include e nutrition 41. Secto oral developm ment strategies that are sensitive to issues of nu utrition are n needed in or rder to reduce the d double burde en of undern nutrition and overweight; ; these shoul ld aim to pro omote the de emand for and supp ply of health hier food and d to eliminat te constraints s to its access and to use of healthier r food. Many secto ors should be b engaged, but mainly agriculture, food proces ssing, trade, social prote ection, education, l labour and public p inform mation. Cro oss-cutting is ssues such as a gender eq quality, qual lity of governance and instituti ions, and pea ace and secu urity should also a be consi idered. These e matters cou uld be considered in the development and d implement tation of a framework f akin a to the W WHO Frame ework Convention n on Tobacco o Control, wh hich has prov vided substan ntial impetus s to the contr rol of tobacco o use. 42. The C Committee on o World Food Security y is preparin ng a global strategic fra amework on n food security and d nutrition. In I the mean ntime, a serie es of genera al principles can be deriv ved from ex xisting policy fram meworks, co ountry expe erience and analysis of o the evide ence. For e example, ch hronic malnutrition n has been successfully s some countri ies in South-East Asia a and Latin Am merica reduced in s thanks to th he simultane eous implem mentation of f policies an nd programm mes aimed a at improving g food security, red ducing pover rty and socia al inequalities s, and enhan ncing materna al education.. 43. For fo food security y, increased access a to foo ods of good nutritional n qu uality1 should d be ensured d in all local marke ets at an af ffordable pri ice all year r round, par rticularly thr rough suppo ort to smallh holder agriculture and women n’s involvem ment but with h considerati ion being gi iven to the p potential negative impact of l labour-displa acing mecha anization and d cash-crop production and of pres ssure on women’s time. In foo od manufact ture, the nut trient profile e, including better micro onutrient con ntent and reduced fats, needs to content of s salt, sugar and a saturated d and trans-f t be improv ved. In the a area of educ cation, better wom men’s educati ion and impr rovements in n water and sanitation ar re associated d with better r child nutrition. 44. Empl loyment poli icies are cru ucial to hous sehold food security, bu ut labour po olicies should d also ensure adeq quate mater rnity protect tion and tha at employee es could wo ork in a be etter environ nment, including pr rotection fro om second-hand smoke, and access to t healthy fo ood. An adeq quate environ nment should be c created in the e workplace for breastfe eeding mothe ers. Social protection p is needed to re edress inequalities and must re each the mos st vulnerable . Cash transf fers to the po oor are used to guarantee e food Food d with high nutr rient density and d low concentra ations of nutrients associated with w increased r risk of noncommunic cable diseases. 1
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needs s. Conditiona al cash transfers, linking the receipt of o cash to br ringing childr dren to health h centres and d schoo ol, can have a positive impact i on ch hildren’s nut tritional statu us, including g increase in n height and d birth weight. 45. Trade mea asures, taxes s and subsid dies are an important means of g guaranteeing access and d enabl ling healthy y dietary ch hoices. They y can be powerful tools when as ssociated wi ith adequate e inform mation for co onsumers thr rough nutriti ion labelling g and respons sible food ma arketing, and d with social l mark keting and pro omotion of healthy h diets and healthy lifestyles. 46. Table 2 pro ovides examp ples of polic cy measures that engage different rele evant sectors s which may y be co onsidered. 47. a for r Member S States Proposed activities (a) revie ew sectoral policies p in a agriculture, social s protec ction, educat tion, labour and trade to o ors in their determine their impac ct on nutrit tion and in nclude nutrit tion indicato r evaluation n framework ks; (b) estab blish a dialo ogue between n health and d other gove ernment secto tors in order r to consider r policy mea asures that could c impro ove the nutri itional status of the pop pulation and d to address s potential conflict c betw ween current t sectoral po olicies and health h polici ies aimed at a improving g nutrition; lement the re ecommendat tions on the marketing of foods and non-alcoholic beverages s (c) impl . to children (resolution WHA63.14) W 48. a for r the Secreta ariat Proposed activities (a) deve elop methodo ological guid delines on th he analysis of o the health h and nutritio on impact of f sectoral po olicies, including that on n different so ocioeconomi ic and other r vulnerable groups (e.g. . indigenous s peoples); (b) ident tify and disse eminate exam mples of goo od practice of sectoral po olicy measure es benefiting g nutrition. 49. a for r internation nal partners s Proposed activities (a) enga age in consu ultations in order to an nalyse the health h and n nutrition imp plications of f existing po olicies involv ving trade, a agriculture, la abour, educa ation, and so ocial protecti ion, with the e aim of iden ntifying and describing d po olicy options s to improve nutritional o outcomes; (b) analy yse evidence e of effectiv veness of in nterventions aimed at im mproving fo ood security, , social welf fare and educ cation in low w-income cou untries. ACT TION 4: To o provide su ufficient hu man and financial reso ources for t the impleme entation of nutr rition interv ventions 50. Technical and a manager rial capabiliti ies are neede ed for implem mentation of f nutrition pro ogrammes at t full s scale and fo or the design n and imple ementation of o multisecto oral policies . Capacity development d t shoul ld be an int tegral part of o plans to extend nutr rition interventions. The e availability y of human n 15 5
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resources li imits the exp pansion of nu utrition actio ons, and the proportion of o primary ca are workers to the population is a major determinant t of program mme effectiv veness. Capacity buildin ng in nutrition is required in b both the health sector at all levels and d other secto ors. ion interven 51. More e financial resources r ar re needed t to increase the coverag ge of nutriti ntions. Currently, n nutrition pro ogrammes rec ceive less th han 1% of ov verall develo opment assis stance. The World W Bank has ca alculated tha at US$ 10 50 00 million w would be nee eded each year to implem ment on a na ational scale top-pr riority nutriti ion intervent tions in the c countries with the highest t burden of m maternal and d child undernutriti ion.1 Further rmore, predictable resou urces are es ssential to sustain s an in ncreased lev vel of programme delivery. 52. Joint efforts are required r of both b governm ments and do onors. Increased resource es may come e from innovative financing mechanisms, m such as the ones discus ssed in the context c of m maternal and child health. 53. Gove ernments nee ed to establish a budget line for nut trition progra ammes and identify fina ancing targets for n nutrition pro ogrammes. Excise taxes ( (for example e, on tobacco o and alcoho ol) may be used to establish na ational funds to expand nu utrition inter rventions. 54. At th he internatio onal level, mechanisms m l and child health prom motion considered for maternal dvance mar include an internationa al financing g facility, ad rket commitments to fu und research h and developmen nt, a “De-T Tax” to earm mark a shar re of value-added taxes s on goods and service es for developmen nt, and volun ntary solidar rity contribu utions throug gh electronic airline ticke et sales or mobile m phone contr racts. Results s-based fund ding as an in ncentive to ac chieve target ts has also be een consider red by donors. 55. From m the expense e side, greate er efficiency y needs to be sought in fu unding progr rammes, incl luding better align nment of don nors’ investm ments with n national prior rities, and measures m to r reduce the cost c of micronutrie ent supplements and ready y-to-use ther rapeutic food d, also by red ducing patent nting fees. 56. Finan ncial monito oring and tr ransparency in the use of resource es will be n needed for better accountability and incre eased efficien ncy. 57. posed activities for Mem mber States Prop (a) identify an nd map capacity needs, a and include capacity-dev velopment in n plans to expand tion actions; nutrit (b) implement a comprehensive app proach to capacity bu uilding, incl luding work kforce devel lopment as well as leadership l d development t, academic c institution nal strengthe ening, organ nizational development and partnersh hips; (c) cost the ex xpansion pla an and quan ntify the exp pected benefits, includin ng the proportion neede ed for capaci ity developm ment and stren ngthening th he delivery of f services; (d) provide su upport to lo ocal commu unities for the t implementation of community y-level nutrit tion actions;
1
Horto on S, et al. Scal ling up nutrition n. What will it c cost? Washingt ton, DC, The World W Bank, 201 10.
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(e) (f) 58.
estab blish a budge et line and na ational financial targets for f nutrition; chan nnel funds ob btained from excise taxes s to nutrition intervention ns.
Proposed activities a for r the Secreta ariat (a) supp port workfor rce developm ership, techn nical and m managerial capacities c in n ment, leade nutrition in n Member St tates through h workshops s, distance learning and c communities s of practice, , and provisi ion of trainin ng materials; (b) make e available refined tool ls for capaci ity building, , and suppo ort the capac city-building g efforts of Member M State es; (c) prov vide costing tools t for nutr rition interve entions.
59.
Proposed activities a for r internation nal partners s (a) follo ow the princi iples of the P Paris Declara ation on Aid Effectivenes ss and the Accra Agenda a for Action, and align do onor support t at country level; nternational competency y standards, specific to th he developm ment of the public p health h (b) set in nutrition workforce, w tha at recognize different tie ers in the wor rkforce (fron ntline worker rs, managers s and specia alists) and di ifferent cont texts for pol licy (i.e. cap pacities for i intersectoral action) and d practice (i. .e. the double burden o f malnutritio on), and sup pport revisio ons of curric cula for preservice and d in-service training of al ll levels of he ealth workers; (c) estab blish academ mic alliance es aimed at a providing institutiona al support to capacity y developme ent in Membe er States; (d) explo ore innovativ ve financing tools for fun nding the exp pansion of nu utrition prog grammes.
ACT TION 5: To o monitor an nd evaluate t the impleme entation of policies p and programme es 60. A well-def fined monitor ring framewo ork is needed to assess progress p mad de towards th he objectives s of th he comprehe ensive implementation p plan. The fra amework ha as to provide e accountab bility for the e action ns implemen nted, resourc ces and resu ults. Table 3 lists propos sed indicator rs for input (policy and d legisl lative frame eworks and d human r resources), output and d outcome (nutrition programme e imple ementation and a food secu urity) and im mpact (nutritio onal status an nd mortality) y). 61. The propos sed set of ind dicators need ds to be adap pted to the co ountry contex xt and priorities, but will l be ret tained for as ssessment pu urposes at the e global leve el. Additional indicators s should be co onsidered for r monitoring progre ess in interse ectoral action n.
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62. Surve eillance syst tems should be establish hed to ensur re regular fl low of infor rmation to policyp makers. Rep porting time should be in n line with na ational priori ities and the requirement ts of the gove erning bodies.1 63. posed activities for Mem mber States Prop (a) develop or r strengthen surveillance systems for r the collection of inform mation on selected input t, output/outc come and im mpact indicato ors; (b) implement the WHO Child C Growth h Standards to monitor individual gr rowth pattern ns and popul lation levels of stunting, wasting and d overweight; ; (c) ensure that t nutrition indicators i ar re adequately y reported in i the annua al review pr rocess recom mmended by y the Comm mission on Information n and Accountability fo for Women’s and Child dren’s Health h in countrie es with lowe est income and a highest burden of m maternal and d child death hs and that so ocial differen ntials are ade equately high hlighted. 64. Prop posed activities for the Secretariat S (a) provide me ethodologica al support for r the collect tion of select ted input, ou utput/outcom me and impac ct indicators, including protocols p and d design of su urveillance systems; (b) ut, output/ou utcome and im mpact indica ators; establish a database of selected inpu
(c) report on global prog gress in de eveloping, st trengthening g and imple ementing na ational nutrit tion plans, po olicies and programmes; (d) 65. support Me ember States in implemen nting the WH HO Child Gr rowth Standa ards.
posed activities for inter rnational par rtners Prop (a) adopt the proposed p fra amework of indicators as s a tool to monitor m the i implementati ion of lopment activ vities; devel (b) support the e collection and a exchang ge of informa ation betwee en organizati ions, with th he aim of ensuring globa al coverage of o the databas ses of input, output/outco ome and imp pact indicator rs.
1 Repo orting implemen ntation of the plan could be co ombined with th he biennial repo orting to the Hea alth Assembly called for in Article 1 11.7 of the Inter rnational Code of Marketing o of Breast-milk Substitutes, S ado opted by the He ealth Assembly in resolution WH HA34.22.
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Table 1a. Effective direct nutrition interventions that can be expanded for delivery through the health system1 All women of reproductive age Iron and folic acid supplementation – daily for pregnant women – intermittent in non-anaemic pregnant women – intermittent in menstruating women living in settings where anaemia is a public health concern Nutrition counselling through foodbased dietary guidelines Calcium supplementation for the prevention and management of preeclampsia and eclampsia Women in special circumstances Appropriate care of women with low body mass index All children aged 0 to 24 months Counselling and support for optimal breastfeeding (early initiation, exclusive breastfeeding for the first six months and continued breastfeeding up to two years of age or beyond) Children in special circumstances Integrated management of severe acute malnutrition through facility- and community-based interventions
Nutritional care and support for HIVinfected pregnant and lactating women Nutritional care and support in emergencies – multiple micronutrient supplementation for pregnant women Iodine supplementation (in case iodized salt is unavailable)
Counselling and support for appropriate complementary feeding Implementation of the Baby-friendly Hospital Initiative
Treatment of moderate acute malnutrition Nutritional care and support for HIVpositive children
Implementation of the International Code of Marketing of Breast-milk Substitutes and relevant resolutions of the World Health Assembly after resolution WHA34.22 Vitamin A supplementation for children from six months to five years of age in vitamin A-deficient populations Iron supplementation for children aged under five years
Nutritional care and support in emergencies
Counselling and support for appropriate infant feeding in the context of HIV infection Counselling and support for appropriate feeding of low-birthweight infants
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Based on individual country needs.
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All women of reproductive age
Women in special circumstances
All children aged 0 to 24 months Zinc supplementation for the management of diarrhoea Nutrition counselling for the adequate care of sick children Home fortification of foods intended for young children Vitamin A administration as part of treatment for measles-related pneumonia for children older than six months
Children in special circumstances
Table 1b. Effective health interventions with an impact on nutrition that can be expanded for delivery through the health system Women of reproductive age Prevention of adolescent pregnancy Pregnancy spacing Intermittent preventive treatment of malaria in pregnant women in high transmission areas Provision of insecticide-treated bednets Children aged 0 to 24 months Properly-timed cord clamping at birth Deworming of children Provision of insecticide-treated bednets Intermittent preventive treatment of malaria in infants, in areas of high transmission in sub-Saharan Africa where plasmodial resistance to sulfadoxine-pyrimethamine is not high Hand washing with soap, and other hygienic interventions
Prevention of exposure to second-hand smoke and cessation of direct tobacco use, alcohol and drug consumption by pregnant women Reduction of indoor air pollution Prevention and control of occupational risks in pregnancy Prevention and control of genitourinary infections in pregnancy Deworming of pregnant women
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Table 2. Sector Agriculture
Non-health interventions with an impact on nutrition Intervention Agricultural activities that generate employment Small-scale agriculture Production of nutrient-rich foods and of staple foods of the poor1 Home gardening and large-scale fruit and vegetable production Micronutrient-rich crop varieties (e.g. orange-flesh sweet potatoes) Diversified food production, and improved storage and processing of food Nutrition counselling integrated into agricultural extension programmes Women’s role in agriculture supported Local production of fortified foods, including fortified flour, oil, salt, sugar, soy and fish sauce, and fortified blended foods Local production of high nutritional quality complementary food with provisions to allow access to all sectors of the population Micronutrient fortification of complementary foods Salt iodization Improvement of the nutritional quality of foods (reduction of the content of salt, fats and sugars, and elimination of trans-fatty acids) Improvement of water supply Improvement of sanitation Women’s primary and secondary education Provision of healthy food in schools and pre-schools Nutrition and physical activity education in school Employment-support policies Healthy nutrition in the workplace Maternity protection in the workplace (through adopting and enforcing the ILO Maternity Protection Convention, 2000 (No. 183) and Recommendation (No. 191)) Smoke-free workplaces Conditional cash transfers Unconditional cash transfers Support for socially disadvantaged groups to access healthy foods Healthy built environments
Food manufacturing
Water and sanitation Education
Labour policies
Social protection
Urban planning
World development report 2008: agriculture for development. Washington, DC, World Bank, 2008. Spielman DJ, Pandya-Lorch R. Millions fed: proven successes in agricultural development. Washington, DC, International Food Policy Research Institute, 2009. Agricultural production contributes to food security, and hence indirectly to redressing undernutrition, both by increasing food availability and by increasing livelihoods and incomes of poor people, so increasing their capacity to feed their families.
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Sector Trade
Intervention Food-price regulatory measures Agricultural subsidies Offer of food in public institutions and private food outlets Food-labelling schemes Regulation of advertising food and beverages to children Implementation of International Code of Marketing of Breast-milk substitutes Use of excise taxes on tobacco and alcohol to finance expansion of nutrition programmes Social marketing for breastfeeding promotion, use of fortified foods, healthy diet and physical activity
Finance Social mobilization
Table 3. Indicators for monitoring the realization of the comprehensive implementation plan Inputs Policy/strategy environment for nutrition: nutrition governance score Human resources: ratio of community health workers to total population Outputs/outcomes Prevalence of children aged under six months who are exclusively breastfed Proportion of children aged under five years who have received two doses of vitamin A supplements1 Impact Incidence of low birth weight
Proportion of stunted children below five years of age Proportion of wasted children below five years of age
Legal frameworks: adoption Proportion of households with and effective implementation of consumption of iodized salt International Code of Marketing of Breast-milk Substitutes Proportion of population with sustainable access to an improved water source Individual food consumption score
Proportion of thin women2 of reproductive age Proportion of children below five years of age with haemoglobin concentration of <11 g/dl Proportion of women of reproductive age (15–49 years) with haemoglobin concentration of <12 g/dl
Proportion of children receiving a minimum acceptable diet at 6–23 months of age
1 2
Children aged 6–59 months in settings where vitamin A deficiency is a public health problem. Women with body mass index <18.5 kg/m2.
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Inputs
Outputs/outcomes Prevalence of children (aged 0– 59 months) with diarrhoea who received oral rehydration therapy and therapeutic zinc Proportion of pregnant women receiving iron and folic acid supplements
Impact Median urinary iodine concentration (μg/l) in children aged 6–12 years Maternal mortality ratio (per 100 000 live births) Infant mortality rate (per 1000 live births) Under-five year mortality rate (per 10 000/day)
=
=
=
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