Maternal, infant and young child nutrition: comprehensive implementation plan on maternal, infant and young child nutrition: biennial report: report by the Director-General

SEVENTY-FIRST WORLD HEALTH ASSEMBLY A71/22 Provisional agenda item 12.6 26 March 2018 Maternal, infant and young child nutrition Comprehensive implementation plan on maternal, infant and young child nutrition: biennial report Report by the Director-General 1. The report describes the progress made in carrying out the comprehensive implementation plan on maternal, infant and young child nutrition endorsed by the Health Assembly in resolution WHA65.6 (2012). It also provides information on the status of national measures to give effect to the International Code of Marketing of Breast-milk Substitutes, adopted in resolution WHA34.22 (1981) and updated through subsequent related Health Assembly resolutions, and describes the progress made in drawing up technical guidance on ending the inappropriate promotion of foods for infants and young children, as welcomed with appreciation by the Health Assembly in resolution WHA69.9 (2016). The Executive Board at its 142nd session considered and noted an earlier version of this report and adopted decision EB142(6), in which inter alia it decided to note the analysis on the extension to 2030 of the 2025 targets on maternal, infant and young child nutrition. 1 PROGRESS MADE IN CARRYING OUT THE COMPREHENSIVE IMPLEMENTATION PLAN ON MATERNAL, INFANT AND YOUNG CHILD NUTRITION Progress towards the global targets 2. Global target 1 (stunting). In 2000, the total number of stunted children under 5 years of age worldwide was 198 million. In 2016, the figure had fallen to 155 million, with 56% of the children concerned living in Asia and 38% in Africa. The downward trend continues. Out of 44 countries with sufficient recent data to estimate progress, 17 are on track and another 19 are showing some progress towards meeting the global target in 2016. 3. Global target 2 (anaemia). The most recent estimates suggest that the global prevalence of anaemia in 2016 among women of reproductive age was 33%, compared with an estimated 30% in 2012, representing an estimated total number of 613 million women of reproductive age with anaemia in 2016. The highest rates are found in central and west Africa and south Asia. 1 See document EB142/22 and the summary record of the Executive Board at its 142nd session, tenth meeting, section 3. A71/22 2 4. Global target 3 (low birth weight). WHO and UNICEF, in collaboration with the academic sector, are currently updating global, regional and national estimates, as well as the methodology used, in order to take into account the high proportion of unrecorded live births. A country consultation on estimated prevalence is ongoing. According to the latest global estimate for the period 2005–2010, 15% of neonates weighed less than 2500 g. 5. Global target 4 (overweight). Globally, in 2016, an estimated 41 million children under 5 years of age (6%) were overweight. Although small, the increase is persistent in both prevalence and numbers. Compared to estimates in 2000, there were 10 million more overweight children in 2016. There is a high prevalence of overweight among children under 5 years of age in southern Africa (12%), central Asia (11%) and northern Africa (10%). 6. Global target 5 (breastfeeding). Globally, in 2011–2016, an estimated 40% of infants under 6 months of age were exclusively breastfed. Based on the latest survey estimates for the period, 33 countries have breastfeeding rates of above 50% and 68 have rates of below 50%. 7. Global target 6 (wasting). Globally, an estimated 52 million children under 5 years of age qualified as wasted in 2016 – of which 17 million were severely wasted. Of these wasted children, 69% lived in Asia and 27% in Africa. Southern Asia is home to over half the world’s wasted children. 8. Countries have expressed the ambition of ending all forms of malnutrition by 2030, including achieving the “internationally agreed targets” on stunting and wasting in children under 5 years of age. 1 When the Executive Board considered the matter at its 138th session, some Member States requested WHO to clarify how the targets contained in the comprehensive implementation plan on maternal, infant and young child nutrition would be aligned with the targets in the 2030 Agenda for Sustainable Development. 2 WHO, in collaboration with UNICEF, has therefore analysed the effect of extending to 2030 the action and level of effort currently under the comprehensive implementation plan on maternal, infant and young child nutrition. 3 The analysis on the extension to 2030 of the 2025 targets on maternal, infant and young child nutrition was noted by the Board in decision EB142(6). This analysis indicates that: for stunting, if the currently agreed annual reduction rate of 4%, achieved by the best performing countries, could be maintained for a further five years, this would lead to a 50% reduction in the number of stunted children (81 million) in 2030; for anaemia, as a decrease in prevalence has not yet been observed, a 50% reduction of the proportion of women of reproductive age with anaemia might be an adequate expectation for 2030; similarly, for low birth weight, a 30% reduction could be expected by 2030; for overweight, applying the rate observed in the best performing countries, global prevalence could be reduced to <3%, thus reversing the rising trend by 2030; for exclusive breastfeeding, also considering the achievements of the best performing countries, 70% of infants could be exclusively breastfed for the first six months of life in 2030; and for wasting, based on the experience of counties that have achieved progress, the global prevalence could be reduced to <3% by 2030. In addition to defining more clearly the expectations to “end all forms of malnutrition” by 2030, this analysis may allow the tracking of progress in the 2030 Agenda for Sustainable Development. 1 United Nations General Assembly resolution 70/1 (2015). Transforming our world: the 2030 Agenda for Sustainable Development. 2 See document EB138/2016/REC/2, summary records of the twelfth meeting, section 4. 3 The rationale followed in the calculation is provided in the WHO/UNICEF discussion paper “The extension of the 2025 Maternal, Infant and Young Child nutrition targets to 2030” (http://www.who.int/nutrition/global-target- 2025/discussion-paper-extension-targets-2030.pdf?ua=1, accessed 22 March 2018). A71/22 3 Action 1: To create a supportive environment for the implementation of comprehensive food and nutrition policies 9. According to the data contained in WHO’s Global database on the Implementation of Nutrition Action (GINA), 1 recently updated with information from the second global nutrition policy review (2016–2017),2 a significantly higher number of countries (189) have national policies and plans that contain explicit goals and strategies to improve nutrition and promote healthy diets. A total of 182 countries include in their policies and plans goals aligned to the global nutrition targets for 2025: 113 targeting stunting, 91 anaemia in women, 101 low birth weight, 141 child overweight, 129 exclusive breastfeeding and 101 wasting. Forty-nine of the 92 countries that have United Nations Development Assistance Frameworks included global nutrition targets in them, in particular for stunting. Moreover, 165 of the 189 countries have also integrated goals related to diet-related noncommunicable disease targets: 92 for sodium/salt intake, 82 for high blood pressure, 132 for diabetes and 152 for overweight and obesity in adults and adolescents. Progress was observed in policies to promote healthy diets and to prevent and manage acute malnutrition. Nutrition labelling now takes place in 122 countries, compared with 51 in the period 2009–2010.3 Similarly, the number of countries that are taking action has increased in the following areas: food reformulation, from 29 in 2009–2010 to 60 in 2016–2017 (in 40 countries the focus is on sodium/salt reduction); trans-fat bans, from 12 to 26; and fiscal policies to promote healthy diets, from 15 to 38 (30 on sugar-sweetened beverages). Countries reporting taking action for treating moderate acute malnutrition increased from 37 in 2009–2010 to 81 in 2016–2017, and for treating severe acute malnutrition, from 47 to 87. 10. Regional plans and strategies continue to be formulated. At its sixty-ninth session, the Regional Committee for South-East Asia endorsed the Strategic Action Plan to reduce the double burden of malnutrition in the South-East Asia Region 2016–2025. Regional nutrition plans reflecting the comprehensive implementation plan on maternal, infant and young child nutrition have been developed in the European and Western Pacific regions covering the period 2015–2020. 11. The Scaling Up Nutrition movement now covers 60 countries and three Indian States. A new strategy and road map have been developed for 2016–2020, with a focus on planning, costing, implementing and financing a common set of nutrition results; and networks of stakeholders are expanding. In 2016, the United Nations network for the movement covered 733 staff members dedicated to nutrition across all countries of the movement, the majority of whom were nationals of the country concerned. The United Nations network focuses its support on nutrition related sectoral and multisectoral policies, strategies, plans and programmes, including setting targets using the SMART approach (ensuring that targets are specific, measurable, attainable, relevant and timely); capacity strengthening for service delivery, including programme implementation; and support for the functioning of multistakeholder coordination platforms. 1 Global database on the Implementation of Nutrition Action (GINA). Available at http://www.who.int/nutrition/gina/en/ (accessed 22 March 2018). 2 Global nutrition policy review 2016−2017: country progress in creating enabling policy environments for promoting healthy diets and nutrition (DRAFT). Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/topics/global- nutrition-policy-review-2016.pdf, accessed 2 March 2018). 3 Global nutrition policy review: what does it take to scale up nutrition action? Geneva: World Health Organization; 2013 (http://www.who.int/nutrition/publications/policies/global_nut_policyreview/en/, accessed 22 March 2018). A71/22 4 12. In response to the revitalized global momentum for improving nutrition and the proclamation in 2016 of the United Nations Decade of Action on Nutrition (2016–2025),1 WHO has developed its strategy, entitled Ambition and Action in Nutrition 2016–2025,2 defining its role, unique value, vision and mission and its theory of change for advancing nutrition during the Decade. Action 2: To include all required effective health interventions with an impact on nutrition in national nutrition plans 13. WHO has continued to develop guidance on effective nutrition interventions, including on the following topics: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services; nutrition in antenatal care; micronutrient supplementation (iron in infants and children, adult women and adolescent girls, and postpartum women); industrial and point-of-use micronutrient fortification (maize flour and corn meal − foods consumed by infants, young children and pregnant women); feeding of infants affected by communicable diseases (Zika virus disease and HIV); and preventive chemotherapy to control soil-transmitted helminth infections. 3 WHO guidelines are disseminated through the eLENA web portal, 4 which now contains 120 titles, as well as eLENAmobile, 5 and through regional and country briefings. Public consultations have been held on the identification of guidance priorities for the next biennium. 14. An analysis of the use of WHO guidelines6 has revealed that: 148 countries are providing breastfeeding counselling, with more emphasis on exclusive breastfeeding for six months than on continued breastfeeding for two years and beyond; 111 countries are implementing the Baby-friendly Hospital Initiative; 120 countries are providing iron supplementation in pregnant women and women of reproductive age; 74 countries are carrying out wheat or maize flour fortification (mainly with iron) and 52 countries point-of-use micronutrient fortification of foods consumed by infants and young children; 67 countries are managing infant feeding in the context of HIV, mainly through replacement feeding; and 69 countries are offering deworming to children and women. Action 3: To stimulate development policies and programmes outside the health sector that recognize and include nutrition 15. Following the Second International Conference on Nutrition, the policy discussion in respect of nutrition and healthy food systems has been given a higher priority by the Committee on World Food Security. The Committee has discussed investment in healthy food systems and in preventing stunting; policies on healthy food environments; and assessing the impact of agricultural policies on nutrition. It has discussed the work programme of the Decade of Action on Nutrition and the progress report of the 1 See United Nations General Assembly resolution 70/259 (2016). 2 Ambition and action in nutrition 2016–2025. Geneva: World Health Organization; 2017 (http://www.who.int/entity/nutrition/publications/nutrition-strategy-2016to2025/en/index.html, accessed 22 March 2018). 3 The guidelines concerned can be found on the nutrition web pages at http://www.who.int/nutrition/publications/en/ (accessed 22 March 2018). 4 WHO e-Library of Evidence for Nutrition Actions (http://www.who.int/elena/en/, accessed 22 March 2018). 5 WHO eLENAmobile for iPhones and Android smartphones (http://www.who.int/elena/eLENAmobile/en/, accessed 22 March 2018). 6 Global nutrition policy review 2016–2017: country progress in creating enabling policy environments for promoting healthy diets and nutrition. Geneva: World Health Organization (in press). A71/22 5 Second International Conference on Nutrition, and a new workstream has been approved for 2018–2019 for the Committee’s engagement in advancing nutrition. WHO has been invited to be a member of the Committee’s Advisory Group. Action 4: To provide sufficient human and financial resources for the implementation of nutrition interventions 16. Governments are investing in interventions that have the potential to address nutrition by tackling poverty through social protection cash transfers, improving water and sanitation supplies and providing school meals. A significantly greater proportion of the domestic budget allocations of governments now goes to sectors that address underlying determinants of nutrition, thereby providing the opportunity to finance a more integrated agenda. Domestic spending by governments on interventions to address undernutrition varies from country to country, with some spending more than 10% of the total budget on nutrition. 1 17. Significant funding gaps in nutrition specific interventions remain. Global spending by donors on nutrition specific interventions only increased by 1% (US$ 5 million) between 2014 and 2015, and, as a proportion of overall overseas development assistance, fell from 0.57% in 2014 to 0.50% in 2015. Spending on the prevention and treatment of diet-related noncommunicable diseases represents just 0.01% of global overseas development assistance. 18. The World Bank investment framework for nutrition2 indicated that an additional investment of US$ 70 billion over 10 years was needed to achieve the global targets for stunting, anaemia in women, exclusive breastfeeding and scaling up treatment for severe wasting. The Global Financing Facility was established to close the financing gap in reproductive, maternal, newborn, child and adolescent health and nutrition. Some 67 countries are eligible to receive financing from the Facility’s Trust Fund. 19. The Nutrition for Growth community invited stakeholders to make new financial and policy commitments at a series of high-level events, including the World Bank Spring Meetings (April 2017) and the African Development Bank Annual Meetings (Ahmedabad, India, 22−26 May 2017), culminating in the Global Nutrition Summit, held in Milan, Italy on 4 November 2017, where US$ 3.4 billion were pledged. Action 5: To monitor and evaluate the implementation of policies and programmes 20. In May 2015, the Sixty-eighth World Health Assembly adopted decision WHA68(14), in which it decided, inter alia: (1) to approve the additional core indicators for the global monitoring framework on maternal, infant and young child nutrition; (2) to recommend that Member States report on the entire core set of indicators starting in 2016, with the exception of progress indicators 1, 4 and 6 and policy environment and capacity indicator 1, which would be reviewed by the Executive Board once available, for approval, and which would be reported on from 2018 onwards; and (3) to request the Director-General to provide additional operational guidance on how to generate the necessary data for 1 Development Initiatives. Global nutrition report 2017: nourishing the SDGs. Bristol, England: Development Initiatives; 2017 (https://www.globalnutritionreport.org/files/2017/11/Report_2017.pdf, accessed 22 March 2018). 2 Shekar M, Kakietek J, Dayton Eberwein J, Walters D. An investment framework for nutrition: reaching the global targets for stunting, anemia, breastfeeding, and wasting. Directions in development – human development. Washington, DC: World Bank; 2017 (https://openknowledge.worldbank.org/handle/10986/26069, accessed 22 March 2018). A71/22 6 indicators in different country contexts. The WHO/UNICEF Technical Expert Advisory Group on Nutrition Monitoring (TEAM) 1 was tasked with further developing and validating the indicators. The Advisory Group has worked on various aspects of the indicators, including their fitness for purpose, appropriateness of definition and the availability of data. An exploratory study was conducted to assess the feasibility of reporting on the indicators. Based on the advice of the Advisory Group, the four remaining indicators and definitions are recommended (see Table). Table. Recommended indicators and definitions Indicator name Definition 1. Minimum dietary diversity Proportion of children 6–23 months of age who received foods from ≥5 food groups 2. Antenatal iron supplementation Proportion of women who consumed any iron-containing supplements during the current or past pregnancy within the last two years 3. Availability of national-level provision of counselling services in public health and/or nutrition programmes Availability of a national programme that includes provision for delivering breastfeeding counselling services to mothers of infants aged 0–23 months through health systems or other community- based platforms 4. Trained nutrition professional density Number of trained nutrition professionals per 100 000 of population in a specified year 21. Operational guidance for these indicators has been based on the advice of the Advisory Group.2 PROGRESS IN IMPLEMENTING THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES AND GUIDANCE ON ENDING THE INAPPROPRIATE PROMOTION OF FOODS FOR INFANTS AND YOUNG CHILDREN 22. In 2016–2017, Member States, partners and the Secretariat continued to accelerate actions to improve infant and young child feeding. Since March 2016, three Member States – Albania, Mongolia and Thailand – have adopted new legal measures to strengthen implementation and monitoring of the International Code of Marketing of Breast-milk Substitutes (“the Code”) and subsequent relevant Health Assembly resolutions. Technical support was provided to Mongolia and Thailand by the Secretariat during the drafting process. 23. To strengthen implementation and monitoring efforts by Member States, WHO’s Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast- milk Substitutes and Subsequent Relevant World Health Assembly resolutions (NetCode) worked on a protocol to provide Member States with practical tools and guidance for setting up effective monitoring systems to help eliminate inappropriate marketing of foods to infants and young children 1 Established in 2015 in response to decision WHA67(9) (2014). 2 WHO, UNICEF. Global Nutrition Monitoring Framework: operational guidance for tracking progress in meeting targets for 2025. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/operational-guidance- GNMF-indicators/en/, accessed 22 March 2018). A71/22 7 and to enable the level of adherence to the Code and national measures to be regularly assessed. The NetCode protocol contains procedures, guidance and tools for: establishing a national monitoring system; detecting, investigating and acting on alleged violations of existing national measures and the Code; and conducting periodic assessments to verify the level of adherence to national measures and the Code and to identify gaps and issues needing to be addressed through policy and legislative measures, programming and investment. 1 The protocol was piloted in selected Member States prior to finalization in October 2017. Chile, Ecuador and Mexico conducted an in-depth survey on inappropriate marketing practices based on the protocol, while Cambodia and Kenya adapted the protocol in preparing an implementation and monitoring framework for enforcement of their national laws governing the Code. Through NetCode, WHO, UNICEF and their partners continued to build the capacity of Member States in effective Code monitoring and implementation. Regional training workshops on Code and protocol implementation for Member States of the Region of the Americas and the Eastern Mediterranean Region were held in Mexico and Oman, respectively. 24. In addition, WHO and UNICEF launched an electronic introduction course on the Code in November 2017. The course is aimed at policy-makers, health practitioners, civil society and relevant staff from international organizations and is publicly accessible. 25. In response to resolution WHA69.9 (2016), the Secretariat prepared an implementation manual to assist Member States in the effective implementation of the WHO guidance on ending inappropriate promotion of foods for infants and young children. The manual provides the rationale for each recommendation contained in the guidance and suggests possible actions for Member States in establishing a legal and policy environment conducive to ending inappropriate promotion of foods for infants and young children. 2 26. In order to enhance the protection, promotion and support of breastfeeding, WHO and UNICEF have taken steps to ensure that all maternity facilities practice the Ten Steps to Successful Breastfeeding. The Ten Steps were revised to reflect the latest science on the critical practices that support breastfeeding in the first few days of life. 3 Accordingly, the implementation guidance for country application of the Baby-friendly Hospital Initiative is being updated, with focus on strengthening health services and a less vertical management and implementation structure. Currently, only 10% of births occur in facilities designated as baby-friendly. The new model does not require an independent designation mechanism and should therefore be both easier to scale up and more sustainable. 1 WHO, UNICEF. NetCode toolkit. Monitoring the marketing of breast-milk substitutes: protocol for ongoing monitoring systems. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/infantfeeding/netcode-toolkit-monitoring-systems/en/, accessed 22 March 2018). 2 Guidance on ending the inappropriate promotion of foods for infants and young children: implementation manual. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/infantfeeding/manual-ending- inappropriate-promotion-food/en/, accessed 22 March 2018). 3 Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017 (http://www.who.int/nutrition/publications/guidelines/breastfeeding- facilities-maternity-newborn/en/, accessed 22 March 2018). A71/22 8 27. In August 2017, WHO and UNICEF jointly published an investment case for breastfeeding 1 and a global breastfeeding scorecard. 2 The investment case documented how an investment of only US$ 4.70 in each newborn is needed to meet the Health Assembly target of increasing the percentage of children aged under 6 months who are exclusively breastfed to at least 50% by 2025. Every dollar invested in breastfeeding would generate US$ 35 in economic returns. The global breastfeeding scorecard showed that no country in the world fully complied with recommended policies and programmes on breastfeeding. 28. In November 2016, WHO assisted in the preparation of a joint statement in support of increased efforts to promote, support and protect breast-feeding articulated by the United Nations Special Rapporteurs on the right to the highest attainable standard of health and on the right to food, the Committee on the Rights of the Child and the Working Group on the issue of discrimination against women in law and in practice. 3 ACTION BY THE HEALTH ASSEMBLY 29. The Health Assembly is invited to note the report. = = = 1 Nurturing the health and wealth of nations: the investment case for breastfeeding. New York, NY/Geneva: UNICEF/World Health Organization; 2017 (http://www.who.int/nutrition/publications/infantfeeding/global-bf-collective- investmentcase.pdf?ua=1, accessed 22 March 2018). 2 Global breastfeeding scorecard, 2017: tracking progress for breastfeeding policies and programmes. New York, NY/Geneva: UNICEF/World Health Organization; 2017 (http://www.who.int/nutrition/publications/infantfeeding/global-bf- scorecard-2017.pdf?ua=1, accessed 22 March 2018). 3 See Joint statement by the UN Special Rapporteurs on the Right to Food, Right to Health, the Working Group on Discrimination against Women in law and in practice, and the Committee on the Rights of the Child in support of increased efforts to promote, support and protect breast-feeding. Geneva: Office of the United Nations High Commissioner for Human Rights (http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=20871&LangID=E, accessed 19 March 2018).