EXECUTIVE BOARD 130th session Provisional agenda item 6.3
EB130/10 15 December 2011
Nutrition Maternal, infant and young child nutrition: draft comprehensive implementation plan Report by the Secretariat
1. In May 2010, the Health Assembly in resolution WHA63.23 on infant and young child nutrition requested the Director-General “to develop a comprehensive implementation plan on infant and young child nutrition as a critical component of a global multisectoral nutrition framework”. In January 2011 the Executive Board noted the preparatory work on such a plan, making several suggestions on its content, including revising its name to cover maternal nutrition and paying more attention to the double burden of undernutrition and overweight.1 In May 2011 the Health Assembly noted the report on the subject and the revised outline of the plan.2 2. In the course of 2011, five regional consultations to collect feedback on the outline of the comprehensive implementation plan have been convened, in the African Region, the Region of the Americas, and the South-East Asia, Eastern Mediterranean and Western Pacific regions. Altogether, the consultations were attended by representatives of different government sectors (health, agriculture, social welfare, education, trade, finance, environment and industry) from 92 Member States, organizations in the United Nations system, development banks, donors and civil society. 3. The annexed draft implementation plan integrates all comments provided by Member States during meetings of WHO’s governing bodies and the regional consultations. It brings together relevant elements from the global strategy for infant and young-child feeding, endorsed by the Health Assembly in resolution WHA55.25 in 2002, the Global Strategy on Diet, Physical Activity and Health, endorsed in resolution WHA57.17 in 2004, and the action plan for the global strategy for the prevention and control of noncommunicable diseases, endorsed in resolution WHA61.14 in 2008. WHO’s framework for priority action for HIV and infant feeding, issued in 2003, has been recently updated to reflect the revised WHO guidelines on the prevention of mother-to-child transmission of HIV.3
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See document EB128/2011/REC/2, summary record of the tenth meeting. See document WHA64/2011/REC/2, summary record of the fourth meeting of Committee B, section 5.
Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a public health approach – 2010 version. Geneva, World Health Organization, 2010; WHO, UNAIDS, UNFPA, UNICEF. Guidelines on HIV and infant feeding. 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. Geneva, World Health Organization, 2010.
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4. Several related regional strategies and plans have been considered in preparing this draft comprehensive plan: the African Union’s Revised African Regional Nutritional Strategy (2005–2015), the Second European Action Plan for Food and Nutrition Policy (2007–2012) (adopted by the Regional Committee for Europe in resolution EUR/RC57/R4 in 2007), the Strategy and Plan of Action for the Reduction of Chronic Malnutrition (endorsed by PAHO’s Directing Council in resolution CD50.R11 in 2010), the Regional strategy on nutrition 2010–2019 (endorsed by the Regional Committee for the Eastern Mediterranean in resolution EM/RC57/R.4 in 2010), the regional nutrition strategy for South-East Asia (whose endorsement by Member States was urged in resolution SEA/RC64/R4 in 2011 by the Regional Committee for South-East Asia) and the Framework for Action on Food Security in the Pacific (endorsed by the Pacific Forum Secretariat at the 41st Pacific Islands Forum (Port Vila, Vanuatu, 4 and 5 August 2010)).1 5. The draft comprehensive implementation plan sets out its rationale, namely the fact that, worldwide, nutrition challenges are multifaceted, effective nutrition actions exist but are not expanded sufficiently, and that new initiatives have been launched. The plan defines its objectives and sets five global targets and a time frame. It further proposes a series of five high-priority actions for Member States, the Secretariat and international partners, and lists effective health interventions and non-health activities that affect nutrition as well as indicators for monitoring the implementation of the plan.
New initiatives in nutrition 6. The optimal strategy to ensure rapid improvement of nutrition requires the implementation of a set of specific nutrition interventions and the integration of nutrition into health, agriculture, education, employment, social welfare and development programmes. The Scaling Up Nutrition movement, launched in 2010, has brought together government authorities from countries with high burden of malnutrition and a global coalition of partners. It calls for intensive efforts to scale up nutrition over the next three-to-five years (2013–2015) through such a strategy. Partners in the movement have committed themselves to work together to mobilize resources, provide technical support, perform high-level advocacy and develop innovative partnerships. 7. In order to respond to the challenges to successful coordination, organizations in the United Nations system have committed themselves to better align their activities at global level through the reform of the United Nations Standing Committee on Nutrition and at country level through the Renewed Efforts against Child Hunger and Undernutrition (REACH) initiative. 8. The initiative for the elimination of new HIV infections in children and improving the health and survival of HIV-infected mothers2 supports the improvement of the nutritional state of mothers and their children. 9. At regional level, a successful example of partnership is the Pan American Alliance for Nutrition and Development for the Achievement of the Millennium Development Goals, launched in 2009.
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See http://www.wpro.who.int/internet/resources.ashx/PIC/2011/PIC9+10+Progress+on+food+security.pdf.
Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, 2011–2015. Geneva, UNAIDS, 2011.
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10. The draft comprehensive implementation plan contributes to the global initiatives by identifying global targets and priority actions in the health sector and defining roles for concerned parties. Specific discussions have been organized with this purpose.
IMPLEMENTATION OF THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES 11. In response to the requirement for biennial reporting,1 this report also provides information on progress made by countries in the implementation of the International Code of Marketing of Breastmilk Substitutes. The comprehensive implementation plan also covers this area and proposes future activities. 12. The implementation of the International Code of Marketing of Breast-milk Substitutes, adopted by the Health Assembly in resolution WHA34.22, and of subsequent related Health Assembly resolutions is not consistent among countries. Statutory regulations have been put in place in 103 Member States and have been drafted in nine. Some 37 Member States rely on voluntary compliance by infant formula manufacturers and 25 Member States have not taken action to enforce the Code; information is missing for 20 Member States.2 13. Among the Member States with legislation, most have provisions on the prohibition of promotion of designated products to the general public and health workers and in health-care facilities, as well as provisions on labelling requirements. Fewer Member States have provisions on contamination warnings, and bans on nutrition and health claims. 14. Less than 50% of countries with legal measures also have legal provisions on monitoring implementation of the Code. Only 37 countries have established functioning monitoring and/or enforcement mechanisms, and limited information on the composition, mandate and functions of such mechanisms is available. 15. Information on implementation of the Code is also provided by regional offices, in collaboration with partners in government and the United Nations system. A recent PAHO review on implementation of the Code in the period 1981–2011 indicates that 16 countries have legal measures and six of them regulate the implementation of the law.3 In 2007 a review by UNICEF of 24 West and Central African countries reported that half those countries had comprehensive legal measures in place.4
Article 11.7 of the International Code; information is collected periodically from Member States by questionnaire, the latest surveys of the status of implementation being issued in 2008 and 2010. Information from UNICEF; these countries also include all Member States that reported on Code implementation, as required under the Code in Articles 11.6 and 11.7. Questionnaires were sent to Member States in 2007 and 2009 and the results were summarized in documents A61/17 Add.1, section F, and A63/9. 30 años del Código en América Latina: Un recorrido sobre diversas experiencias de aplicación del Código Internacional de Comercialización de Sucedáneos de la Leche Materna en la Región entre 1981 y 2011. Washington DC, PAHO, 2011. 4 Sokol E, Aguayo V, Clark D. Protecting breastfeeding in West and Central Africa: 25 years implementing the International Code of Marketing of Breast-milk Substitutes. Dakar, UNICEF Regional Office for West and Central Africa, 2007. 3 2
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16. An analysis by the Secretariat of nutrition policies in Member States in 20101 highlighted the following challenges: legislation can only be applied in public health facilities, does not provide clear operational guidance, and is poorly enforced and inadequately monitored; health workers are not adequately trained; and the public is not adequately informed.
ACTION BY THE EXECUTIVE BOARD 17. The Board is invited to note the report and give further guidance on the comprehensive implementation plan for maternal, infant and young child nutrition.
See http://www.who.int/nutrition/EB128_18_Backgroundpaper1_A_review_of_nutritionpolicies.pdf (accessed 1 December 2011).
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ANNEX DRAFT COMPREHENSIVE IMPLEMENTATION PLAN ON MATERNAL, INFANT AND YOUNG CHILD NUTRITION
RATIONALE Global nutrition challenges are multifaceted 1. Adequate provision of nutrients, beginning in early stages of life, is crucial to ensure good physical and mental development and long-term health. Poor availability or access to food of adequate nutritional quality or the exposure to conditions that impair absorption and use of nutrients has led to large sections of the world’s population being undernourished, having poor vitamin and mineral status or being overweight and obese, with large differences among population groups. These conditions are often present simultaneously and are interconnected. 2. In women, both low body mass index and short stature are highly prevalent in low-income countries, leading to poor fetal development, increased risk of complications in pregnancy, and the need for assisted delivery.1 In some countries in south-central Asia, more than 10% of women aged 15–49 years are shorter than 145 cm. In sub-Saharan Africa, south-central and south-eastern Asia, more than 20% of women have a body mass index less than 18.5 kg/m2 and this figure is as high as 40% in Bangladesh, Eritrea and India. Conversely, an increased proportion of women start pregnancy with a body mass index greater than 30 kg/m2, leading to increased risk of complications in pregnancy and delivery as well as heavier birth weight and increased risk of obesity in children. 3. Iron-deficiency anaemia affects 30% of women of reproductive age (468 million), and 42% of pregnant women (56 million). Maternal anaemia is associated with reduced birth weight and increased risk of maternal mortality. Anaemia rates have not improved appreciably over the past two decades.2 4. Every year an estimated 13 million children are born with intrauterine growth restriction3 and about 20 million with low birth weight.4 A child born with low birth weight has a greater risk of morbidity and mortality and is also more likely to develop noncommunicable diseases, such as diabetes and hypertension, later in life.
Black RE et al. Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet, 2008; 371:243-260. Data are also taken from the Monitoring and Evaluation to Assess and Use Results Demographic and Health Surveys (MEASURE DHS) project (http://www.measuredhs.com/Data/, accessed 1 December 2011). 2 United Nations System Standing Committee on Nutrition. Progress in nutrition: Sixth report on the world nutrition situation. Geneva, United Nations System Standing Committee on Nutrition Secretariat, 2010. 3 de Onis M, Blössner M, Villar J. Levels and patterns of intrauterine growth retardation in developing countries. European Journal of Clinical Nutrition, 1998; 52(Suppl.1):S5-S15.
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United Nations Children’s Fund and World Health Organization, Low birthweight: country, regional and global estimates. New York, United Nations Children’s Fund, 2004.
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5. In 2010 about 115 million children worldwide were underweight, 55 million had low weight for their height and 171 million children under the age of five years had stunted growth.1 The proportion of children under the age of five years in developing countries who were underweight is estimated to have declined from 29% to 18% between 1990 and 2010, a rate that is still inadequate to meet the Millennium Development Goal 1, Target 1.C of halving levels of underweight between 1990 and 2015. Sufficient decline took place in Asia and Latin America, but considerable efforts are still needed in Africa. In addition, in 2010, 43 million preschool children in developing and developed countries were overweight or obese.2 The prevalence of childhood obesity in low- and middle-income countries has been accelerating in the past 10 years; WHO estimates that in 2015 the rate will reach 11%, close to the prevalence in upper-middle-income countries (12%). Obese children are likely to grow into obese adults; have an increased risk of type 2 diabetes, liver disease and sleep-associated breathing disorders; and have diminished chances of social and economic performance in adult life. 6. Anaemia affects 47.4% (293 million children) of the preschool-age population,3 and 33.3% (190 million) of the preschool-age population globally is deficient in vitamin A4. 7. Nutritional status is also influenced by several environmental factors. In countries where the prevalence of HIV infection is high, HIV infection has both a direct impact on the nutritional status of women and children who are infected and an indirect effect through alterations in household food security and inappropriate choices of infant-feeding practices in order to prevent mother-to-child transmission of HIV. Poor food security also increases risk-taking behaviour by women that places them at increased risk of becoming infected with HIV. Tobacco use (both smoking and smokeless tobacco) during pregnancy adversely affects fetal health. Direct maternal smoking as well as exposure to second-hand smoke during pregnancy increases the risk of complications in pregnancy, including low birth weight and preterm birth. More people are smoking in many low- to middle-income countries, in particular young girls and women of reproductive age. Although the proportion of women smoking is low in many countries, the women and their offspring still face substantial risks of adverse pregnancy outcomes because of their exposure to second-hand smoke. Use of tobacco transmits tobacco contaminants to the fetus through the placenta and to neonates through breast milk. Expenditure on tobacco also limits the capacity of families to provide better nutrition for pregnant women and children. 8. Childhood malnutrition is the underlying cause of death in an estimated 35% of all deaths among children under the age of five years. More than two million children die each year as a result of undernutrition before the age of five years and iron-deficiency anaemia is estimated to contribute to a significant number of maternal deaths every year in low- and middle-income countries. Maternal and child undernutrition account for 11% of the global burden of disease.5
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Underweight and stunting, in: World Health Statistics 2010, Geneva, World Health Organization, 2010. +2 standard deviations or more above the median of the WHO standards.
De Benoist B, McLean E, Egli I, Cogswell M (Eds). Worldwide prevalence of anaemia 1993–2005: WHO global database on anaemia. Geneva, World Health Organization, 2008, pp.1–40. Global prevalence of vitamin A deficiency in populations at risk 1995–2005: WHO global database on vitamin A deficiency. Geneva, World Health Organization, 2009. Black RE et al. Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008; 371:243–260. 5 4
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9. Malnutrition has a negative impact on cognitive development, school performance and productivity. Stunting and iodine and iron deficiencies, combined with inadequate cognitive stimulation, are leading risk factors contributing to the failure of an estimated 200 million children to attain their full development potential. Each 1% increase in adult height is associated with a 4% increase in agricultural wages1 and eliminating anaemia would lead to an increase of 5% to 17% in adult productivity. Malnutrition is an impediment to the progress towards achieving Millennium Development Goals 1 (Eradicate extreme poverty and hunger), 2 (Achieve universal primary education), 3 (Promote gender equality and empower women), 4 (Reduce child mortality), 5 (Improve maternal health) and 6 (Combat HIV/AIDS, malaria and other diseases).
Effective nutrition actions exist but are not implemented on a sufficiently large scale 10. A review and policy analysis of Member States in 2009–20102 indicated that most countries have a range of policies and programmes on nutrition. However, such policies are often inadequate in face of the complexity of the challenges of maternal, infant and young child nutrition and do not produce the expected impact. 11. Even when nutrition policies exist, they have not always been officially adopted, often do not articulate operational plans and programmes of work with clear goals and targets, timelines and deliverables; they do not specify roles and responsibilities for those involved, or identify workforce and capacity needs; and they do not include process and outcome evaluation. 12. The policy review indicated that correcting maternal undernutrition was not a priority in countries with a high burden of maternal mortality. Few of the 36 countries with the greatest burden of undernutrition implement at a national scale the full set of effective interventions to prevent child underweight and maternal undernutrition and to foster early child development. 13. Interventions that can be managed directly by the health sector lack detailed implementation guidance and are only partially implemented where health systems are weak. Many countries have adopted integrated strategies for maternal, newborn and child health that incorporate nutrition interventions, but the actual delivery of nutrition support in health services is often inadequate and few indicators are available to measure the coverage. 14. National development strategies do not take nutrition in due consideration. National food and nutrition policies often focus on information and informed-choice models and give little attention to structural, fiscal and regulatory actions aimed at changing unfavourable food environments. 15. Programme implementation is not well coordinated among different actors. In all regions most coordination and administration of policies occurred within health ministries, with variable input from ministries of education, agriculture, food and welfare. Policy and programme implementation often depends on external funding and is not sustainable. Monitoring of activities is not regularly done or poorly done.
1 Haddad L, Bouis HE. The impact of nutritional status on agricultural productivity: wage evidence from the Philippines. Warwick (United Kingdom of Great Britain and Northern Ireland), Development Economics Research Centre. Papers, No. 97, 1989.
See http://www.who.int/nutrition/EB128_18_Backgroundpaper1_A_review_of_nutritionpolicies.pdf (accessed 1 December 2011).
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16. The implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent related Health Assembly resolutions is not consistent among countries. Statutory regulations have been put in place in 103 Member States and have been drafted in 9; 37 Member States rely on voluntary compliance by infant formula manufacturers, and 25 Member States have not taken action to enforce the Code; information is missing for 20 Member States.1 17. In most of those 103 Member States, the legislation makes provisions for the prohibition of promotion of designated products to the general public and health workers and in health-care facilities, and sets labelling requirements. Fewer Member States have provisions on contamination warnings, and bans on nutrition and health claims. 18. Less than 50% of countries with legal measures also have legal provisions on monitoring implementation of the Code. Only 37 of those countries have established functioning monitoring and/or enforcement mechanisms, and limited information on the composition, mandate and functions of such mechanisms is available. 19. Regional offices continue to update the information on implementation of the Code. A recent PAHO review on implementation over the period 1981–20112 indicated that 16 countries have legal measures and six of them regulate the implementation of the relevant law. In a review in 2007 UNICEF found that, of 24 West and Central African countries,3 half had comprehensive legal measures in place.
OBJECTIVE, TARGETS AND TIME FRAME 20. The plan aims to alleviate the double burden of malnutrition in children, starting from the earliest stages of development. Substantial benefits can be obtained by concentrating efforts from conception through the first two years of life, but at the same time a life-course approach needs to be considered so that good nutritional status can be maintained. 21. Progress can be made in the short term, and most nutrition challenges can be resolved within the current generation. For example, currently available nutrition interventions should be able to avert at least one third of the cases of stunting in the short term.4 However, full elimination of some conditions may require a longer time frame and commitment for a decade of investment to expand nutrition interventions should be made, with the aim of averting one million child deaths per year. This plan therefore has a 10-year time frame (2012–2021). Reporting will be done biennially.
Information from UNICEF; these countries also include all Member States that reported on implementation of the Code, as required in Articles 11.6 and 11.7. Questionnaires were sent to Member States in 2007 and 2009 and the results were summarized in documents A61/17 Add.1, section F, and A63/9. 2 Sokol E, Aguayo V, Clark D. Protecting breastfeeding in West and Central Africa: 25 years implementing the International Code of Marketing of Breast-milk Substitutes. Dakar, UNICEF Regional Office for West and Central Africa, 2007. 3 30 años del Código en América Latina: Un recorrido sobre diversas experiencias de aplicación del Código Internacional de Comercialización de Sucedáneos de la Leche Materna en la Región entre 1981 y 2011. Washington DC, PAHO, 2011.
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Bhutta ZA et al. for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371:417–440.
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22. Global targets are important for the measurement of achievements and to develop accountability frameworks. Targets are needed for nutrition conditions that are responsible for a large burden of nutrition-related morbidity and mortality from conception through the first two years of life: stunting, maternal anaemia and low birth weight.1 Child underweight – of which stunting represents the largest fraction – is the largest cause of deaths and disability-adjusted life years in children under the age of five years, and iron deficiency contributes to maternal mortality in low- and middle-income countries. Such targets would complement and underpin Target 1.C of Millennium Development Goal 1 in relation to reducing the prevalence of underweight children. Under that Goal, a fourth target on childhood overweight is warranted, given the rapid increase observed globally in the prevalence of that condition. The proposed targets are based on country experiences and the existence of effective interventions. Global targets will need to be adapted at the country level. 23. Global target 1: 40% reduction of childhood stunting by 2022. Reduction in stunting has been documented in some countries in South America and in South-East Asia. In Brazil, the prevalence of stunting in children younger than five years decreased from 37% in 1974–1975 to 7% in 2006–2007 (i.e. a 30% absolute reduction of stunting, or an average relative reduction of 2.7% per year in 30 years).2 In areas of Bangladesh where the Integrated Management of Childhood Illness was implemented, stunting rates in children aged 24–59 months have dropped from 63.1% to 50.4% (i.e. a 13% absolute reduction, or an average relative reduction of 4% per year in five years).3 A global target of a 4% relative reduction per year is compatible with these achievements. 24. Global target 2: 50% reduction of anaemia in women of reproductive age by 2022. Some countries have demonstrated a reduction in the prevalence of anaemia in non-pregnant women, with a relative reduction of 3% to 6% per year. However, there is no intrinsic biological reason for the pace in reduction, and suitable strategies (fortification, supplementation, and dietary diversification) can be put in place in order to achieve reduction in a shorter time frame. A 5% relative reduction per year can be considered. Considering that about half the cases of anaemia are due to iron deficiency, this target corresponds to the virtual elimination of iron-deficiency anaemia. 25. Global target 3: 50% reduction of low birth weight by 2022. Establishing a target for the reduction of the prevalence of low birth weight is challenging in view of the limited availability of data and the poor quality of information. 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 9% per year, and therefore a global target of 5% relative reduction per year seems realistic. 26. Global target 4: No increase in childhood overweight by 2022. The prevalence of overweight in children under the age of five years has been steadily growing in the past 10 years, with relative 1 The development of global targets has been requested by Member States during regional consultation. Draft targets have been discussed at the regional consultations in the Region of the Americas and the Eastern Mediterranean Region but broader discussion with Member States is required at the Executive Board and through electronic consultation. 2 3
Victora CG et al. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377:1863–1876.
Arifeen SE et al. Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial. Lancet 2009; 374:393–403.
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increases of 3% to 5% per year. Success in curbing increasing rates in school-age children has been documented in Chile, France and Sweden, although limited to some regions and to higher income groups. 27. Global target 5: Increase exclusive breastfeeding rates in the first six months up to at least 50% by 2022. Globally, exclusive breastfeeding rates increased from 14% in 1985 to 38% in 1995, but decreased subsequently in most regions. However, rapid and substantial increases in exclusive breastfeeding rates, often exceeding the proposed global target, have been achieved in individual countries in all regions, such as Cambodia (from 12% to 60% between 2000 and 2005), Mali (from 8% to 38% between 1996 and 2006) and Peru (from 33% to 64% between 1992 and 2007).
ACTIONS 28. This action plan illustrates a series of priority actions that should be jointly implemented by Member States and international partners. Specific regional and country adaptation will be needed, led by the relevant national and regional institutions. ACTION 1: To create a supportive environment for the implementation of comprehensive food and nutrition policies 29. Progress towards nutrition goals requires high-level policy commitment and broad societal support. Existing food and nutrition policies need to be reviewed so that they comprehensively meet all main nutrition challenges and deal with the distribution of those problems within society. A further aim of such review is to ensure that nutrition is placed centrally in other sectoral policies and in overall development policy. Crucial factors for the successful implementation of these policies are: (a) official adoption by relevant governmental bodies; (b) the establishment of an intersectoral governance mechanism; (c) the engagement of development partners; and (d) the involvement of local communities. The private sector may also contribute to a better food supply and to increased employment and therefore income. 30. Proposed activities for Member States (a) revise nutrition policies so that they comprehensively address the double burden of malnutrition with a human rights-based approach and an official endorsement by parliament or government; (b) include nutrition in the country’s overall development policy, Poverty Reduction Strategy Papers and relevant sectoral strategies; (c) establish effective intersectoral governance mechanisms for implementation of nutrition policies at national and local levels that contribute towards policy integration across sectors; (d) engage local governments and communities in the design of plans to expand nutrition actions and ensure their integration in existing community programmes; (e) establish a dialogue with relevant national and international parties and form alliances and partnerships to expand nutrition actions.
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Proposed activities for the Secretariat (a) provide support to Member States, on request, in strengthening national nutrition policies and strategies, and nutrition components of other sectoral policies including national development policies and Poverty Reduction Strategy Papers; (b) improve access to normative and policy guidelines, knowledge products, tools and expert networks.
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Proposed activities for international partners (a) implement global advocacy initiatives that increase public awareness of the need to expand actions on nutrition; (b) strengthen international cooperation on nutrition in order to harmonize standards, policies and actions through adequate mechanisms and intergovernmental bodies, such as the World Health Assembly, the Committee on World Food Security and the United Nations Economic and Social Council; (c) engage in international coordination mechanisms or partnerships, including the Scaling Up Nutrition movement and the United Nations System Standing Committee on Nutrition.
ACTION 2: To include all required effective health interventions with an impact on nutrition in national nutrition plans 33. Many diverse interventions aimed at changing behaviours, providing nutritional support and reducing the exposure to several environmental risk factors have been shown to be effective and should be considered for implementation at national scale. Tables 1a and 1b list effective direct nutrition interventions and health interventions that have an impact on nutrition that can be delivered by the health system. The lists include interventions that need to be considered either for selected population groups or in special circumstances, including emergencies. Analysis of the evidence is summarized in a background paper to this plan1 and reported in the WHO e-Library of Evidence for Nutrition Actions2. WHO’s guideline process ensures that evidence is continuously updated and that gaps in research are identified. 34. The greatest benefits result from improving nutrition in the early stages of life. However, a lifecourse approach to improving nutrition is also needed, with activities targeting older children and adolescents besides infants and young children, in order to ensure the best possible environment for mothers before conception so as to reduce the incidence of low birth weight and to break the
Essential nutrition actions. Improving maternal-newborn-infant and young child health and nutrition. Geneva, World Health Organization, 2011. 2
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http://www.who.int/elena/en/ (accessed 1 December 2011).
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intergenerational cycle of malnutrition. Management of childhood overweight would also require action throughout the school years.1 35. Interventions should be integrated into existing health-care systems to the extent possible. They should be linked to existing programmes and delivered as packages, in order to improve cost efficiency. Implementation of WHO’s approaches and interventions – Integrated Management of Childhood Illness, Integrated Management of Adolescent and Adult Illness and Integrated Management of Pregnancy and Childbirth – will be essential. Furthermore, strengthening health systems forms a central element of a successful nutrition strategy. 36. Design of packages of intervention can be based on country needs and the level of investment. Community-based programmes that integrate different direct nutrition interventions in primary care, with systems to ensure universal access, should be prioritized as being cost-effective. A group of organizations in the United Nations system has jointly produced the United Nations OneHealth Costing Tool – software that can easily be adapted to different country contexts.2 37. Proposed activities for Member States (a) include all proven nutrition interventions in maternal, child and adolescent health services; (b) adopt a national policy on elimination of mother-to-child transmission of HIV in accordance with the latest guidelines; (c) strengthen health systems, promote universal coverage and principles of primary health care; (d) develop or where necessary strengthen legislative, regulatory and/or other effective measures to control the marketing of breast-milk substitutes in order to ensure implementation of the International Code of Marketing of Breast-milk Substitutes and relevant resolutions adopted by the Health Assembly. 38. Proposed activities for the Secretariat (a) review, update and expand WHO’s guidance on and tools for effective nutrition actions, highlight good practice of delivery mechanisms and disseminate the information; (b) apply cost-effectiveness analysis to health interventions with an impact on nutrition;
(c) provide support to Member States, on request, in implementing policies and programmes aimed at improving nutritional outcomes;
Population-based prevention strategies for childhood obesity: report of a WHO forum and technical meeting, Geneva, 15–17 December 2009. Geneva, World Health Organization, 2010. http://www.internationalhealthpartnership.net/CMS_files/userfiles/OneHealth%20leaflet%20May2011.pdf (accessed 1 December 2011). 2
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(d) provide support to Member States, on request, in their efforts to develop or where necessary strengthen and monitor legislative, regulatory and other effective measures to control marketing of breast-milk substitutes; (e) 39. convene a meeting with academic partners to develop a prioritized research agenda.
Proposed activities for international partners (a) align plans for development assistance to nutrition actions recognized as effective;
(b) support the nutrition components of health strategies for maternal and child health, such as the Integrated Maternal Newborn and Child Health Strategy. ACTION 3: To stimulate development policies and programmes outside the health sector that recognize and include nutrition 40. Sectoral development strategies that are sensitive to issues of nutrition are needed in order to reduce the double burden of undernutrition and overweight; these should aim to promote the demand for and supply of healthier food and to eliminate constraints to its access and to use of healthier food. Many sectors need to be engaged, but mainly agriculture, food processing, trade, social protection, education, labour and public information. Cross-cutting issues such as gender equality, quality of governance and institutions, and peace and security should also be considered. These matters could be considered in the development and implementation of a framework akin to the WHO Framework Convention on Tobacco Control, which has provided substantial impetus to the control of tobacco use. 41. The Committee on World Food Security is preparing a global strategic framework on food security and nutrition. In the meantime, a series of general principles can be derived from existing policy frameworks, country experience and analysis of the evidence. For example, chronic malnutrition has been successfully reduced in some countries in South-East Asia and Latin America thanks to the simultaneous implementation of policies and programmes aimed at improving food security, reducing poverty and social inequalities, and enhancing maternal education. 42. For food security, increased access to foods of good nutritional quality1 should be ensured in all local markets at an affordable price all year round, particularly through support to smallholder agriculture and women’s involvement but with consideration being given to the potential negative impact of labour-displacing mechanization and cash-crop production and of pressure on women’s time. In food manufacture, the nutrient profile, including better micronutrient content and reduced content of salt, sugar and saturated and trans-fatty acids, needs to be improved. In the area of education, better women’s education and improvements in water and sanitation are associated with better child nutrition. 43. Employment policies are crucial to household food security, but labour policies should also ensure adequate maternity protection and that employees could work in a better environment, including protection from second-hand smoke, and access to healthy food. Social protection is needed to redress inequalities and must reach the most vulnerable. Cash transfers to the poor are used to Food with high nutrient density and low concentrations of nutrients associated with increased risk of noncommunicable diseases. 1
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guarantee food needs. Conditional cash transfers, linking the receipt of cash to bringing children to health centres and school, can have a positive impact on children’s nutritional status, including increase in height and birth weight. 44. Trade measures, taxes and subsidies are important means of guaranteeing access and enabling healthy dietary choices. They can be powerful tools when associated with adequate information for consumers through nutrition labelling and responsible food marketing, and with social marketing and promotion of healthy diets and healthy lifestyles. 45. Table 2 provides examples of policy measures that engage different relevant sectors which may be considered. 46. Proposed activities for Member States (a) review sectoral policies in agriculture, social protection, education, labour and trade to determine their impact on nutrition and include nutrition indicators in their evaluation frameworks; (b) establish a dialogue between health and other government sectors in order to consider policy measures that could improve the nutritional status of the population and to address potential conflict between current sectoral policies and health policies aimed at improving nutrition. 47. Proposed activities for the Secretariat (a) develop methodological guidelines on the analysis of the health and nutrition impact of sectoral policies, including that on different socioeconomic and other vulnerable groups (e.g. indigenous peoples); (b) identify and disseminate examples of good practice of sectoral policy measures benefiting nutrition. 48. Proposed activities for international partners (a) engage in consultations in order to analyse the health and nutrition implications of existing policies involving trade, agriculture, labour, education, and social protection, with the aim of identifying and describing policy options to improve nutritional outcomes; (b) analyse evidence of effectiveness of interventions aimed at improving food security, social welfare and education in low-income countries. ACTION 4: To provide sufficient human and financial resources for the implementation of nutrition interventions 49. Technical and managerial capabilities are needed for implementation of nutrition programmes at full scale and for the design and implementation of multisectoral policies. Capacity development should be an integral part of plans to extend nutrition interventions. The availability of human resources limits the expansion of nutrition actions, and the proportion of primary care workers to the
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population is a major determinant of programme effectiveness. Capacity building in nutrition is required in both the health sector at all levels and other sectors. 50. More financial resources are needed to increase the coverage of nutrition interventions. Currently, nutrition programmes receive less than 1% of overall development assistance. The World Bank has calculated that US$ 10 500 million would be needed each year to implement at national scale top-priority nutrition interventions in the countries with the highest burden of maternal and child undernutrition.1 Furthermore, predictable resources are essential to sustain an increased level of programme delivery. 51. Joint efforts are required of both governments and donors. Increased resources may come from innovative financing mechanisms, such as the ones discussed in the context of maternal and child health. 52. Governments need to establish a budget line for nutrition programmes and identify financing targets for nutrition programmes. Excise taxes (for example, on tobacco and alcohol) may be used to establish national funds to expand nutrition interventions. 53. At the international level, mechanisms considered for maternal and child health promotion include an international financing facility, advance market commitments to fund research and development, a “De-Tax” to earmark a share of value-added taxes on goods and services for development, and voluntary solidarity contributions through electronic airline ticket sales or mobile phone contracts. Results-based funding as an incentive to achieve targets has also been considered by donors. 54. From the expense side, greater efficiency needs to be sought in funding programmes, including better alignment of donors’ investments with national priorities, and measures to reduce the cost of micronutrient supplements and ready-to-use therapeutic food, also by reducing patenting fees. 55. Financial monitoring and transparency in the use of resources will be needed for better accountability and increased efficiency. 56. Proposed activities for Member States (a) identify and map capacity needs, and include capacity-development in plans to expand nutrition actions; (b) implement a comprehensive approach to capacity-building, including workforce development as well as leadership development, academic institutional strengthening, organizational development and partnerships; (c) cost the expansion plan and quantify the expected benefits, including the proportion of costs needed for capacity-development and strengthening the delivery of services; (d) provide support to local communities for the implementation of community-level nutrition actions;
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Horton S, et al. Scaling up nutrition. What will it cost? Washington, DC, The World Bank, 2010.
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(e) (f) 57.
establish a budget line and national financial targets for nutrition; channel funds obtained from excise taxes to nutrition interventions.
Proposed activities for the Secretariat (a) support workforce development, leadership, technical and managerial capacities in nutrition in Member States through workshops, distance learning and communities of practice, and provision of training materials; (b) make available refined tools for capacity-building, and support the capacity-building efforts of Member States; (c) provide costing tools for nutrition interventions.
58.
Proposed activities for international partners (a) follow the principles of the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action, and align donor support at country level; (b) set international competency standards, specific to the development of the public health nutrition workforce, that recognize different tiers in the workforce (frontline workers, managers and specialists) and different contexts for policy (i.e. capacities for intersectoral action) and practice (i.e. the double burden of malnutrition), and support revisions of curricula for preservice and in-service training of all levels of health workers; (c) establish academic alliances aimed at providing institutional support to capacitydevelopment in Member States; (d) explore innovative financing tools for funding the expansion of nutrition programmes.
ACTION 5: To monitor and evaluate the implementation of policies and programmes 59. A well-defined monitoring framework is needed to assess progress made towards the objectives of the comprehensive implementation plan. The framework has to provide accountability for the actions implemented, resources and results. Table 3 lists proposed indicators for input (policy and legislative frameworks and human resources), output and outcome (nutrition programme implementation and food security) and impact (nutritional status and mortality). 60. The proposed set of indicators needs to be adapted to the country context and priorities, but will be retained for assessment purposes at the global level. Additional indicators should be considered for monitoring progress in intersectoral action.
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61. Surveillance systems should be established to ensure regular flow of information to policymakers. Reporting time should be in line with national priorities and the requirements of the governing bodies.1 62. Proposed activities for Member States (a) develop or strengthen surveillance systems for the collection of information on selected input, output/outcome and impact indicators; (b) ensure that nutrition indicators are adequately reported in the annual review process recommended by the Commission on Information and Accountability for Women’s and Children’s Health in countries with lowest income and highest burden of maternal and child deaths and that social differentials are adequately highlighted. 63. Proposed activities for the Secretariat (a) provide methodological support for the collection of selected input, output/outcome and impact indicators, including protocols and design of surveillance systems; (b) establish a database of selected input, output/outcome and impact indicators;
(c) report on global progress in developing, strengthening and implementing national nutrition plans, policies and programmes. 64. Proposed activities for international partners (a) adopt the proposed framework of indicators as a tool to monitor the implementation of development activities; (b) support the collection and exchange of information between organizations, with the aim of ensuring global coverage of the databases of input, output/outcome and impact indicators.
1 Reporting implementation of the plan could be combined with the biennial reporting to the Health Assembly called for in Article 11.7 of the International Code of Marketing of Breast-milk Substitutes, adopted by the Health Assembly in resolution WHA34.22.
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Table 1a. Effective direct nutrition interventions that can be expanded for delivery through the health system 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 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) 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 Nutritional care and support in emergencies 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 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 facilityand community-based interventions
Counselling and support for appropriate infant feeding in the context of HIV infection
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All women of reproductive age
Women in special circumstances
All children aged 0 to 24 months Iron supplementation for children aged under five years 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 Counselling and support for appropriate feeding of low-birthweight infants
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 Children aged 0 to 24 months Properly-timed cord clamping at birth Deworming of children
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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
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Women of reproductive age
Children aged 0 to 24 months
Prevention of exposure to second-hand smoke and cessation of direct tobacco Hand washing with soap, and other hygienic interventions 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. Non-health interventions with an impact on nutrition Sector Agriculture Intervention Agricultural activities that generate employment Small-scale agriculture Production of nutrient-rich foods and 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 Food manufacturing Local production of fortified foods, including fortified flour, oil, salt, sugar, soy and fish sauce, and fortified blended foods 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) Water and sanitation Education 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 Labour policies 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 Social protection Conditional cash transfers Unconditional cash transfers Support for socially disadvantaged groups to access healthy foods
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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Urban planning Trade
Healthy built environments 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
Finance Social mobilization
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
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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 Household 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 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)
Proportion of children receiving a minimum acceptable diet at 6–23 months of age 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
=
=
=
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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