LANDSCAPE ANALYSIS TO ACCELERATE ACTIONS TO IMPROVE … · This Nutrition Landscape Analysis report...

LANDSCAPE ANALYSIS TO

ACCELERATE ACTIONS TO

IMPROVE MATERNAL AND

CHILD NUTRITION IN NAMIBIA

REPUBLIC OF NAMIBIA

MINISTRY OF HEALTH AND SOCIAL SERVICES

Directorate: Primary Health Care Services

Division: Family Health

Subdivision: Food and Nutrition

Private Bag 13198

Windhoek, Namibia

September 2012

i

FOREWORD

All children are born with the same potential, and the right to grow and develop according to

their individual capabilities. In Namibia, a third of all children under five years of age are

suffering from stunting or low height for age, with all the short- and long-term negative

consequences to the physical growth and mental development of our children that this implies.

The Government of the Republic of Namibia has made great efforts since Independence to

improve the health and nutritional status of the Namibian people. Despite these efforts,

maternal and child under-nutrition still constitute a major public health problem in Namibia.

As part of the effort to improve maternal and child nutrition, Namibia joined the Scaling Up

Nutrition (SUN) movement in 2011. The SUN movement requires countries to conduct a

Nutrition Landscape Analysis to assess the readiness and capacity of the countries to scale up

nutrition. In collaboration with our development partners, we have been engaged to assess the

existing gaps and constraints in the country, and identify opportunities to integrate and scale

up new and existing evidence-based and cost effective multi-sectoral nutrition action.

As the Chair of the Namibian Alliance for Improved Nutrition (NAFIN), I am proud to be at the

helm of the movement to improve the nutritional status of our men, women and children in

Namibia. I vow to continue raising the political commitment and resource allocation for

nutrition in order to realize the goals and objectives of Vision 2030 and the National

Development Plan NDP4.

I commend the efforts of the Ministry of Health and Social Services, which has successfully

conducted this study in collaboration with the World Health Organization and other

development partners in Namibia.

I call upon all government ministries, parastatals, community structures, the University of

Namibia, non-governmental organisations, the private sector, the United Nations agencies, and

other bilateral agencies to read and use this report, with the vision of improving the nutrition

and food security of the Namibian population.

I thank all those who, in diverse ways, helped to make this study and report possible.

………………………………………………….

RIGHT HONOURABLE NAHAS ANGULA, MP

PRIME MINISTER OF THE REPUBLIC OF NAMIBIA

ii

PREFACE

The Ministry of Health and Social Services (MoHSS) recognizes the contribution of good nutrition

to the socio-economic development of the nation. In cognizance of this fact, the Ministry has

developed several programmes to address various maternal, infant, and young child nutrition

problems in the country. A National Nutrition Strategic Plan 2011-2015 was developed to guide

the MoHSS and partners in delivering effective evidence-based nutrition interventions in the

country.

This Nutrition Landscape Analysis report marks a major achievement in the history of the

Ministry of Health and Social Services at a time when food and nutrition interventions require

the commitment of many sectors, from community to national level, in government and among

development partners, that are tasked with working together for the successful scaling up of

nutrition actions in Namibia.

This report describes the methodologies used for assessing and classifying commitment to

nutrition in Namibia, and the strengths and weaknesses as well as opportunities and threats

to Namibia’s capacity to scale up nutrition interventions.

The study focuses on the identification of constraints at multi-sectoral levels for scaling up

nutrition-related activities and on making strategic and specific recommendations for national

plans of actions to scale up nutrition in Namibia.

The Nutrition Landscape Analysis to assess the country’s readiness to accelerate the actions to

reduce maternal and child malnutrition in Namibia was carried out by the Directorate of

Primary Health Care Services of the Ministry of Health and Social Services, in collaboration with

the World Health Organization.

I fervently hope that the findings of this study will be beneficial to the future policymakers in

their efforts to reduce and prevent negative nutrition-related health impacts, and will thus

contribute to sustainable social and economic development in Namibia.

……………………………………………..

DR. RICHARD NCHABI KAMWI, MP

MINISTER OF HEALTH AND SOCIAL SERVICES

iii

Message from the WHO Representative

The challenges that Namibia faces in addressing food security and nutrition need a concerted

multi-sectoral and multidisciplinary response.

The global strategy on infant and young child feeding, endorsed by the World Health Assembly

in 2002 (resolution WHA55.25), advocates for comprehensive national policies that aim to foster

environments that protect, promote, and support appropriate infant and young child feeding

practices, including exclusive breastfeeding.

The Global Strategy on Diet, Physical Activity and Health, endorsed in 2004 by the World Health

Assembly (Resolution WHA57.17), recognizes that a life-course perspective is essential for

addressing all aspects of nutrition. In 2008, the World Health Assembly further endorsed an

action plan for the global strategy for the prevention and control of non-communicable diseases

(Resolution WHA61.14). This action plan promotes healthy lifestyles that include appropriate

diet and physical exercise as key elements to avoid risk factors for non-communicable diseases.

Several regional strategies have highlighted the need to address the double burden of

malnutrition. The African Union’s Revised African Regional Nutritional Strategy 2005–2015 urged

greater awareness among Africa’s leaders of the essential contribution of food and nutrition

security to the implementation of strategies for socio-economic development of the continent

and achieving the Millennium Development Goals.

This Nutrition Landscape Analysis assesses Namibia’s readiness to accelerate actions in nutrition

by identifying areas of greatest return on investment and determining how best to invest in

order to yield maximum benefits. It also builds on the work and experiences of countries in

developing and implementing national nutrition policies and plans, and looks specifically at the

set of interventions proven to be effective in addressing maternal and child under-nutrition.

The analysis came at the right moment to feed information into the SUN movement, which

Namibia joined in the recent past.

The Nutrition Landscape Analysis has two components. The first is a desk review of national

policies, strategies, programmes and budgets for nutrition, and who is doing what and where in

Namibia. The second component comprises fieldwork to interview key informants from

different government sectors; health, nutrition, and development partners; non-governmental

organisations; and health workers and managers, and to assess facilities providing nutrition

interventions in the country. The assessment was done through the exemplary collaborative

efforts of different line ministries, UN agencies, bilateral and multilateral organisations, NGOs

and the University of Namibia. We would like to thank all stakeholders for their active

participation in this exercise.

The World Health Organization commends the leadership of the Right Honourable Prime

Minister and the Honourable Minister of Health and Social Services in promoting coordinated

efforts from all stakeholders towards the reduction of maternal and child malnutrition in

Namibia.

WHO reiterates its unwavering support for the successful implementation of Government

policies, strategies and plans to reduce and eventually eliminate malnutrition, and thus

contribute to the socio-economic development of Namibia.

Dr Magda Robalo Correia e Silva

WHO Representative

v

AUTHORS’ ACKNOWLEDGEMENTS

We gratefully acknowledge the continued leader sh ip of the Directorate of Primary Health

Care Services of the Ministry of Health and Social Services in realizing the finalisation of the

Nutrition Landscape Analysis in Namibia.

Our heartfelt gratitude also goes to the assessment team composed of the Ministry of Health

and Social Services Directorate of PHC; the Directorate of Policy Planning through the National

Health Training Centre (NHTC); the Ministry of Education; the Ministry of Agriculture, Water

and Forestry; the Ministry of Gender Equality and Child Welfare; the Ministry of Defence; the

Ministry of Information and Communications Technology; the University of Namibia; and

Synergos, Global Alliance for Improved Nutrition (GAIN), Food and Nutrition Technical

Assistance (FANTA-3) Project, International Technical and Educational Center for Health (I-

TECH), the United States Agency for International Development (USAID), the United Nations

Children’s Fund (UNICEF), the World Food Programme (WFP), the World Health Organization

(WHO), the Centres for Disease Control (CDC) and the Namibian Alliance for Improved Nutrition

(NAFIN).

We also appreciate the meaningful contribution of the Maternal, Child Health and Nutrition

Committee, who provided their inputs individually and collectively to enrich this important

document.

Our sincere gratitude and appreciation goes to the World Health Organization Headquarters in

Geneva and the Namibia Country Office for financial and technical support throughout the

study, with special emphasis on data analysis and the final report.

We would also like to express our sincere appreciation to all stakeholders at national, regional

and district levels who contributed to this study by providing valuable information and for

expressing their views; their inputs contributed to the quality of information included in this

report.

Last but not least, our special thanks go to the mothers and children of Namibia for their

patience and cooperation during fieldwork, and without whom our efforts would be fruitless.

vi

ACRONYMS and ABBREVIATIONS

AIDS Acquired immune deficiency syndrome

ANC Antenatal care

BMI Body mass index

CAA Catholic AIDS Action

CACCOCs Constituency AIDS coordinating committees

CSOs Civil society organisations

DAPP Development Aid from People to People in Namibia

DCC District coordinating committee

DSP Directorate of Special Programming

FANTA Food and Nutrition Technical Assistance

FAO Food and Agriculture Organization

FSNAP National Food Security and Nutrition Action Plan

FSNC National Food Security and Nutrition Council

FSNP Food Security and Nutrition Project

GAIN Global Alliance for Improved Nutrition

GMP Growth Monitoring and Promotion

GRN Government of the Republic of Namibia

HIV Human immunodeficiency virus

IEC Information, education, communication

IMAM Integrated Management of Acute Malnutrition approach

IMNCI Integrated Management of Newborn and Childhood Illness programme

IMR Infant mortality rate

I-TECH International Technical and Educational Center for Health

IYCF Infant and young child feeding

MAM Moderate acute malnutrition

MAWF Ministry of Agriculture, Water and Forestry

MCH Maternal and child health

vii

MDG s Millennium Development Goals

MIYCN Maternal, infant and young child nutrition

MoHSS Ministry of Health and Social Services

MUAC Mid upper arm circumference

NACS Nutrition Assessment Counselling and Support programme

NAFIN Namibian Alliance for Improved Nutrition

NCD Non-communicable diseases

NDHS National Demographic and Health Survey

NFNP Food and Nutrition Policy for Namibia (usually referred to as the ‘National

Food and Nutrition Policy’)

NGOs Non-governmental organisations

NLSA Nutrition Landscape Analysis

PHC Primary health care

PLHIV People living with HIV/AIDs

PMTCT Prevention of mother-to-child transmission (of HIV)

RACCOCs Regional AIDS coordinating committees

RCC Regional coordinating committee

RMT Regional management team

RUTF Ready-to-use therapeutic foods

SAM Severe acute malnutrition

SUN Scaling Up Nutrition movement

U5MR Under-five mortality rate

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WASH Water, sanitation and hygiene activities

WFP World Food Programme

WHO World Health Organization

viii

GLOSSARY

1. INFANT AND YOUNG CHILD FEEDING DEFINITIONS1

Exclusive breast milk: to meet the definition, the practice requires that the infant

receive breast milk (including milk expressed or from a wet nurse). The practice allows

the infant to also receive drops and syrups (vitamins, minerals, medicines) but no other

foods are allowed.

Predominant breastfeeding: to meet the definition the practice requires that the infant

receive breast milk (including milk expressed or from a wet nurse) as the predominant

source of nourishment. The practice also allows the infant to receive certain liquids

(water, water-based drinks, and fruit juices), oral rehydration salts, and drops and syrups

(vitamins, minerals, medicines). No other food-based fluids or non-human milks are

allowed.

Breastfeeding: to meet the definition, the practice requires that the infant receives

breast milk (including milk expressed or from a wet nurse). The practice allows the infant

to receive anything else; any food or liquid including non-human milk and formula.

Bottle-feeding: this infant feeding practice includes the provision of any liquid (including

breast milk) or semi-solid food from a bottle with nipple/teat. The practice allows the

infant to receive anything else; any food or liquid including non-human milk and formula.

Complementary feeding: to meet the definition the practice requires that the infant

receive breast milk (including milk expressed or from a wet nurse) and solid or semi-solid

foods. The practice allows the infant to receive anything else; any food or liquid including

non-human milk and formula.

Minimum dietary diversity (MDD): this is the proportion of children 6-23 months of age

who receive food from four or more food groups. The food groups used for tabulation of

minimum dietary diversity are 1) grains, roots and tubers; 2) legumes and nuts; 3) dairy

products (milk, yogurt, cheese); 4) flesh foods (meat, fish, poultry and liver/organ meats);

5) eggs; 6) vitamin A-rich foods and vegetables; and 7) other fruits and vegetables. The

cut-off of at least four of the above seven food groups was selected because it is

associated with better quality diets for both breastfed and non-breastfed children.

Minimum meal frequency (MMF): this is the proportion of breastfed and non-breastfed

children 6-23 months of age who receive solid, semi-solid or soft foods (but also including

milk feeds for non-breastfed children) the minimum number of times or more. The

minimum is defined as two times per day for breastfed infants 6-8 months; three times per

day for breastfed children 9-23 months; and four times per day for non-breastfed children

6-23 months. ‘Meals’ include both meals and snacks (other than trivial amounts) and

frequency is based on caregiver reports.

Minimum acceptable diet (MAD): this is the proportion of children 6-23 months of age who

receive a minimum acceptable diet (apart from breast milk).

1 Source: http://whqlibdoc.who.int/publications/2008/9789241596664_eng.pdf

http://whqlibdoc.who.int/publications/2008/9789241596664_eng.pdf

ix

2. ANTHROPOMETRIC INDICATORS:2

Stunting: moderate and severe below minus two standard deviations from median

height-for-age of reference population.

Wasting: moderate and severe below minus two standard deviations from median

weight-for-height of reference population.

Underweight: moderate below minus two standard deviations from median weight-for-

age of reference population; severe below minus three standard deviations from median

weight-for-age of reference population.

3. ACUTE MALNUTRITION DEFINITIONS 3

Moderate acute malnutrition (MAM) is defined by WHO/UNICEF as: Weight-for-Height Z-

score <-2 but >-3.

Severe acute malnutrition (SAM) is defined by WHO/UNICEF as: MUAC<11.5cm; Weight-

for-Height Z-score <-3; bilateral pitting oedema; marasmic-kwashiorkor (both wasting and

oedema).

2 Source: http://www.unicef.org/infobycountry/stats_popup2.html

3 Source: http://www.unicef.org/nutrition/training/2.3/13.html

http://www.unicef.org/infobycountry/stats_popup2.html

http://www.unicef.org/nutrition/training/2.3/13.html

x

TABLE OF CONTENTS

FOREWORD .......................................................................................................... i

PREFACE ............................................................................................................ ii

Message from the WHO Representative ............................................................... iii

AUTHORS’ ACKNOWLEDGEMENTS....................................................................... v

ACRONYMS and ABBREVIATIONS ....................................................................... vi

GLOSSARY ....................................................................................................... viii TABLE OF CONTENTS .......................................................................................... x

LIST OF TABLES ............................................................................................... xiii

LIST OF FIGURES ............................................................................................. xiv

EXECUTIVE SUMMARY ........................................................................................ 1

PART I: BACKGROUND INFORMATION ................................................................. 4

1.1 BACKGROUND/INTRODUCTION ................................................................... 4 1.2 NAMIBIA COUNTRY PROFILE: GENERAL ...................................................... 4

1.2.1 Map of Namibia ........................................................................................... 5

1.3 HEALTH SERVICES IN NAMIBIA................................................................... 6 1.4 NUTRITION SERVICES IN NAMIBIA .............................................................. 7 1.5 HEALTH STATUS INDICATORS .................................................................... 9

1.6 HEALTH FINANCING IN NAMIBIA ............................................................... 10 1.7 NAMIBIA: THE FIGHT AGAINST MALNUTRITION ........................................ 10

1.7.1 History of global commitment: ................................................................... 10

1.7.2 History of Namibia’s commitment: the national Food Security and Nutrition Project (FSNP) ............................................................................. 11

1.7.3 The Namibia Alliance for Improved Nutrition (NAFIN) ................................. 13

1.7.4 The Scaling Up Nutrition (SUN) movement – Namibia membership ............ 16 1.8 DEVELOPMENT OF PLANS, POLICIES AND GUIDELINES TO FIGHT

MALNUTRITION ......................................................................................... 16

1.8.1 The ‘National Food and Nutrition Policy’ (NFNP) ......................................... 16 1.8.2 The National Food Security and Nutrition Action Plan (1995) ....................... 17

1.8.3 The National Strategic Plan for Nutrition (2011-2015) .................................. 18 1.9 NUTRITION-SPECIFIC AND SENSITIVE POLICIES AND LEGISLATION.......... 18 1.10 GLOBAL MALNUTRITION SITUATION ......................................................... 21

1.11 OVERVIEW OF THE NUTRITION SITUATION IN NAMIBIA ............................ 21 1.11.1 Over-nutrition and non-communicable diseases ........................................ 24 1.11.2 Micronutrient deficiency situation ............................................................. 25

1.11.3 Infant and young child feeding (IYCF)........................................................ 27 1.11.4 Food intake patterns ................................................................................. 29

1.12 NUTRITION IN DIFFICULT CIRCUMSTANCES ............................................. 30

1.12.1 Nutrition in emergencies ........................................................................... 30 1.12.2 HIV and nutrition ...................................................................................... 31

1.12.3 Alcohol and nutrition ................................................................................ 31

xi

PART II: IN-DEPTH ASSESSMENT ...................................................................... 32

2.1 METHODOLOGY ........................................................................................ 32 2.1.1 Preparation ............................................................................................... 33

2.2 PURPOSE OF THE NLSA ............................................................................ 34 2.3 STUDY INSTRUMENTS ............................................................................... 35 2.4 DATA ANALYSIS ........................................................................................ 36

2.5 RESPONDENTS .......................................................................................... 36 2.6 RESULTS ................................................................................................... 40

2.6.1 Awareness of nutrition problems and underlying causes, as perceived by stakeholders ......................................................................................... 40

2.6.2 Documents used for nutrition advocacy ..................................................... 42

2.6.3 Commitment of stakeholders to scale up nutrition action .......................... 42 2.6.4 How would nutrition be scaled up with existing resources? ....................... 43

2.7 RESOURCE ALLOCATION FOR NUTRITION................................................. 49

2.8 INTEGRATION: INCORPORATION OF NUTRITION INTO PLANS AND PROGRAMMES .......................................................................................... 49

2.9 COORDINATION FOR NUTRITION .............................................................. 51

2.9.1 National coordination mechanisms ............................................................ 51 2.9.2 Regional coordination mechanisms............................................................ 51 2.9.3 Involvement of government sectors and partners in nutrition coordination 51

2.9.4 Support to regions and facilities ................................................................ 52 2.10 HUMAN RESOURCES FOR NUTRITION ....................................................... 53

2.10.1 Capacity to act .......................................................................................... 53

2.10.2 Human resources and quality of services ................................................... 54 2.11 HUMAN RESOURCES WITH NUTRITION TRAINING ..................................... 59

2.11.1 In-service training ..................................................................................... 60 2.11.2 Health worker knowledge .......................................................................... 61 2.11.3 Counselling skills: quality of counselling given by health workers .............. 62

2.11.4 Self-reported ability and knowledge to address nutrition problems............. 63 2.11.5 Counselling and support for appropriate breastfeeding and the reported

content of messages provided .................................................................... 65

2.12 MANAGEMENT OF SEVERE ACUTE MALNUTRITION (SAM) AND THE ADVICE AND TREATMENT PROVIDED .................................................................... 67

2.12.1 Management of SAM and MAM and the availability of adequate

and relevant supplies ................................................................................ 68 2.12.2 Management of moderate acute malnutrition and the advice given............. 69 2.12.3 Implementation of key nutrition activities recommended for women .......... 70

2.12.4 Nutrition-sensitive interventions recommended for women carried out at facility level ........................................................................................... 71

2.13 NUTRITION EDUCATION CARRIED OUT AT HEALTH FACILITIES................ 72 2.13.1 Health worker capacity, motivation and time to conduct nutrition duties ... 73

2.14 MANAGEMENT SYSTEMS ........................................................................... 76

2.14.1 Nutrition information and availability of nutrition data .............................. 76 2.14.2 Communication of nutrition information to communities ........................... 81 2.14.3 Supplies .................................................................................................... 81

2.15 IEC MATERIALS ........................................................................................ 83 2.16 PROTOCOLS AND GUIDELINES .................................................................. 84

PART III: DISCUSSIONS AND CONCLUSIONS ...................................................... 87

Recommendations ............................................................................................... 88

xii

PART IV: REGIONAL PROFILES .......................................................................... 90

1. Regional profile: Caprivi Region ........................................................................ 91 2. Regional profile: Erongo Region ........................................................................ 93

3. Regional profile: Hardap Region ....................................................................... 95 4. Regional profile: Karas Region .......................................................................... 97

5. Regional profile: Kavango Region ................................................................. 99100

6. Regional profile: Khomas Region .................................................................... 101

7. Regional profile: Kunene Region ..................................................................... 103 8. Regional profile: Ohangwena Region ............................................................... 105 9. Regional profile: Omaheke Region .................................................................. 107

10. Regional profile: Omusati Region .............................................................. 10910

11. Regional profile: Oshana Region .................................................................. 111 12. Regional profile: Oshikoto Region ................................................................ 113 13. Regional profile: Otjozondjupa Region .......................................................... 115

BIBIOGRAPHY ................................................................................................. 117

ANNEX I: NUTRITION LANDSCAPE ANALYSIS SURVEY TEAM ........................... 123

ANNEX II: LIST OF INDIVIDUALS/ORGANISATIONS THAT PARTICIPATED IN THE

PROCESS OF NUTRITION LANDSCAPE ANALYSIS FOR NAMIBIA ....................... 124

ANNEX III: NUTRITION LANDSCAPE ANALYSIS SURVEY QUESTIONNAIRES ...... 125

xiii

LIST OF TABLES

Table 1: National policies, guidelines and other documents related to

nutrition-specific and nutrition-sensitive actions ......................................... 18

Table 2: Legislation enacted to support nutrition activities ........................................ 21

Table 3: Magnitude of nutritional problems among children in Namibia ..................... 22

Table 4: List of regions and districts for in-depth assessment .................................... 34

Table 5: Number of respondents at national level (in-depth assessment) .................... 36

Table 6: Number of stakeholders interviewed at regional level .................................... 37

Table 7: Number of respondents at district level ........................................................ 38

Table 8: Number of facility managers interviewed at facility level ................................ 38

Table 9: Number of health workers interviewed at facility level ................................... 39

Table 10: Respondents by NGO ................................................................................. 40

Table 11: Integration into other sectoral programmes ................................................ 50

Table 12: Disaggregated responses of health workers regarding adequate support ..... 52

Table 13: Number of health workers trained in various areas of nutrition

(indicated on Form 5) ................................................................................. 60

Table 14: Knowledge test on various nutrition interventions among health workers ... 61

Table 15: Nutrition topics discussed during counselling............................................. 62

Table 16: Criteria used to assess health worker knowledge in counselling a mother

in the context of HIV .................................................................................. 64

Table 17: Where does nutrition education and counselling take place? ..................... 745

Table 18: Summary of health workers’ responses regarding nutrition tasks ............... 75

Table 19: Summary of the information on nutrition indicators, use of data and

receipt of feedback, and the use of feedback at national level in Namibia ......... 77


receipt of feedback, and the use of feedback in the health system of the

regions of Namibia .................................................................................... 7980


receipt of feedback, and the use of feedback by NGOs at regional level ............. 80

Table 22: Summary of methods of information dissemination to communities

in the regions ............................................................................................. 81

Table 23: Number of health facilities visited ............................................................... 81

Table 24: Number of health workers interviewed ........................................................ 81

xiv

LIST OF FIGURES

Figure 1: Regional prevalence of malnutrition among children under five years

of age in Namibia (NDHS 2006) ................................................................... 23

Figure 2: IYCF practices in Namibia in 2000 and 2006. ............................................. 28

Figure 3: Timely and appropriate introduction of complementary food

in Namibia.................................................................................................. 29

Figure 4: Regional and national figures: perceived major nutrition problems .............. 41

Figure 5: Regional and national figures: perceived causes of nutrition problems ........ 42

Figure 6: Documents used for nutrition advocacy ...................................................... 42

Figure 7: Distribution of staff with appropriate skills at all levels ............................... 54

Figure 8: Number of regions implementing recommended community-based

MCH activities. ........................................................................................... 55

Figure 9: Number of regions implementing recommended community-based education-

related nutrition activities, as informed by district-level managers ....................... 56

Figure 10: Number of regions implementing recommended community-based food

security/livelihoods/income-generating activities .............................................. 57

Figure 11: Number of regions implementing recommended community-based water

and sanitation activities ..................................................................................... 57

Figure 12: Number of regions implementing recommended community-based IYCF

activities and prevention of mother-to-child transmission (PMTCT) as

informed by district-level managers ................................................................... 58

Figure 13: Staff with nutrition training ...................................................................... 59

Figure 14: Numbers of staff working in nutrition ....................................................... 60

Figure 15: Interventions implemented at facility level to address child health ........... 62

Figure 16: National average of self-assessed health worker knowledge in counselling

mothers on breastfeeding in the context of HIV ................................................. 64

Figure 17: Number of facilities providing counselling and support for appropriate

complementary feeding, and the reported content of messages .......................... 65

Figure 18: Percentage of facilities providing counselling and support for appropriate

breastfeeding, and the reported content of messages ......................................... 66

Figure 19: Number of facilities that treat SAM (with and without complications) and

content of treatment and advice ........................................................................ 67

Figure 20: Number of facilities that are doing SAM management, and availability of

relevant material and supplies ........................................................................... 68

Figure 21: Percentage of respondents on management of moderate acute

malnutrition (MAM) and advice ....................................................................... 69

Figure 22: Percentage of facilities that implement key nutrition interventions

recommended for women. ......................................................................... 70

xv

Figure 23: Number of nutrition-sensitive interventions implemented at

facility level ............................................................................................... 71

Figure 24: Nutrition education................................................................................... 72

Figure 25: Health workers’ responses regarding time to undertake

nutrition duties......................................................................................... 73

Figure 26: IEC materials available at facility level ...................................................... 83

Figure 27: Availability of protocols/guidelines at health facilities ............................... 84

Figure 28: Number of respondents reporting protocols related to child

nutrition-related interventions in stock in health facilities ......................... 85

Figure 29: Number of health facility managers that reported the availability of stocks

of protocols on women’s nutrition interventions and infection control

interventions in health facilities ................................................................... 86

1

LANDSCAPE ANALYSIS TO ACCELERATE ACTIONS TO IMPROVE MATERNAL AND CHILD NUTRITION IN NAMIBIA, September 2012

EXECUTIVE SUMMARY

Namibia has shown significant improvements in maternal and child health indicators

during the past few decades. However, indicators related to nutritional status have not

shown comparable improvements in maternal and child under-nutrition therefore

these still comprise a significant public health problem. In Namibia, provision of health

care to the population is mainly delivered by the state. Health services are provided

free of charge to the recipient and include a wide array of programmes focusing both on

preventive and curative health care. The preventive services are more focused on

maternal and child health services, which have significant inputs in nutrition.

A Nutrition Landscape Analysis to identify the readiness to accelerate actions on

reduction of maternal and child under-nutrition was undertaken in Namibia. It aimed

at identifying critical health system constraints for scaling up nutrition-related

activities; engaging with key policymakers and senior managers by analysing the

capacity gaps hindering the optimal scaling up of nutrition-related activities; making

strategic, relevant and specific recommendations to the national plans of actions in

the scaling up of nutrition-related activities; and building the capacity of national,

provincial and district personnel in conducting detailed nutrition programmatic

assessments through their participation in this process.

The study comprised three components: the first focused on a desk review of the

current nutrition situation in the country along with the interventions that are

ongoing; the second consisted of an in-depth country assessment; and the third

component was the development of regional profiles summarising the nutritional

status indicators and their determinants and identifying programme-related issues at

the regional level through the in-depth country assessment.

A descriptive study aimed at obtaining relevant information at the different levels of

the health system (national, regional, district and operational) using a series of study

instruments developed by WHO (with appropriate country-specific modifications) was

carried out.

At the national level, stakeholders in the health sector and the non-health sector

were included, and semi-structured interviews were conducted to obtain information.

All 13 regions were included, and in addition the regional directors or chief medical

officers of the regions were also interviewed. At the district level, the district medical

officer was interviewed.

A two-stage stratified sampling of operational-level service facilities was undertaken.

Trained investigators visited these facilities to make observations using a checklist and

interviews were conducted with the health workers and the facility managers. The

other groups interviewed were representatives from donor agencies and from

national-level non-governmental organisations (NGOs).

2


Commitment at the highest political level is well demonstrated. A majority of

national- and regional-level stakeholders identified the common nutritional problems

and their causes. Lack of coordination within the health sector and between health

sector and other sectors, limitations in resources (both financial and human), and poor

targeting of interventions were the perceived barriers for scaling up nutrition actions

as identified by both health and non-health sector national-level stakeholders.

Contributions that the stakeholders could make to support the scaling up of nutrition

action ranged from policy development to capacity building, conducting research, and

developing interventions for moderate acute malnutrition (MAM).Improving general

awareness, changing behaviour at community level, and better inter-sectoral

coordination were among the others. A majority of national-level stakeholders were

satisfied with national nutrition policy, though less so among provincial stakeholders.

Integration of nutrition interventions into the MCH package implemented at all levels

of the health system indicated that programmes proposed in the policy were being

practiced at all levels. Nutrition-related activities have been incorporated into

programmes in the education, agriculture, and social and economic development

sectors to some extent. The main funding source for the nutrition programme is the

government, with financial assistance from development partners. Non-availability of

a budget line for nutrition in the health budget is noteworthy.

Coordination activities are present at the highest political level as well as at the

Ministry of Health and Social Services at national, regional and district levels. Even

though involvement of other sectors also has been reported, such collaboration needs

strengthening. NGO sector involvement is limited and is linked with provision of

services.

Personnel in the health sector at all levels are the key providers of nutrition-related

services, hence there is no separate category of ‘nutrition staff’. In addition to the

basic training, many categories of staff receive in-service training in nutrition-related

areas, either locally or on a limited scale overseas.

Training opportunities are linked with the programmes. A majority of field-level

health staff considered the training to be relevant to their job functions and indicated

the need for more training in selected areas. Training materials on selected aspects

related to nutrition are prepared at the national level even though availability of such

materials at the field level needs improvement.

Health workers’ knowledge was satisfactory except in selected areas: in growth

monitoring and promotion; management of severe or moderate malnutrition; and

breastfeeding in the context of HIV/AIDS. Nutrition education and counselling only

takes place at health facility levels.

A broad-based nutrition policy is required to include other key sectors, and strategic

plans need to be developed focusing on the contributions to be made by each line

3


ministry. An effective mechanism to improve coordination within the health sector

and between health and other sectors needs to be strengthened.

All regional and district plans should include nutrition as a component and use all

available data at each level to develop such plans evidence-based planning. For this

to happen, timely availability of good quality information and the development of

planning capabilities at regional and district level are necessary.

There is a need to streamline availability of guidelines, availability of drugs,

appropriate ‘information, education, communication’ (IEC) materials and other

requirements at all service outlets. Community empowerment programmes need to be

implemented focusing on improvement of health and nutrition.

Allocation of funds for nutrition-related activities needs to be streamlined, especially

in the health sector, and it may be necessary to consider a separate budget line for

finances related to nutrition activities.

Wide variations are seen between regions in policy- and programme-related issues

pertaining to nutrition.

4


PART I: BACKGROUND INFORMATION

1.1 BACKGROUND/INTRODUCTION

Namibia, as a country aiming to address malnutrition and carrying forward the findings

of the Lancet Series on Maternal and Child Nutrition, decided to undertake a Nutrition

Landscape Analysis (NLSA). This assessment activity was initiated by the World Health

Organization (WHO) to assess readiness to accelerate action in nutrition in

participating countries. On the global stage, in October 2007 WHO partnered up with

other concerned partner agencies including the Food and Agriculture Organization of

the United Nations (FAO), the Global Alliance for Improved Nutrition (GAIN), Helen

Keller International (HKI), the United Nations Standing Committee on Nutrition (SCN),

the United Nations Children's Fund (UNICEF) and the World Food Programme (WFP)

to initiate an interagency effort to strengthen their contribution, together with

national governments, towards the achievement of the Millennium Development Goals

(MDGs).

This report outlines Namibia’s NLSA in-depth assessment.

1.2 NAMIBIA COUNTRY PROFILE: GENERAL

Namibia is situated in the south-western part of Africa, bordering with Angola in the

north, Botswana in the east, Zambia and Zimbabwe in the northeast, South Africa in

the south and the Atlantic Ocean in the west. It is a land of contrasts, with arid, semi-

arid and savannah land. The total surface area is 824,124 square kilometres and the

country currently has a population of 2.1 million. The country is divided into 13

administrative regions.

Namibia is an upper-middle income country, ranked 120 out of 187 countries on the

United Nations Development Programmes’ Human Development Index in 2011. This

classification is based on many indicators, including the GINI coefficient used to assess

the actual income/expenditure distribution inside a country. A Gini coefficient of 0.74

puts Namibia amongst countries with the highest income inequalities in the world.

Since Independence in 1990, provision of basic social services such as health and

education has improved through a government programme of primary health care and

the rapid expansion of health facilities and schools. Health facilities are now more

equitably distributed throughout the country. As a result, access and quality of health

services has increased.

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1.2.1 Map of Namibia

Rainfall in Namibia varies greatly from place to place and from season to season. As a

result, the country is prone to emergencies such as drought and floods that have a

bearing on both crop and livestock farming practices and which create long-term

economic effects on productivity. There is inadequate access to water and sanitation,

particularly in rural areas. According to the Namibia Demographic and Health Survey,

2006-2007, two thirds of the population have non-improved household sanitation

facilities and nearly 20 per cent of the population require 30 minutes or longer to

walk to obtain drinking water.

Close to 51 per cent of the active population are unemployed and 36.5 per cent are

subsistence farmers.4 In Namibia, there is only one agricultural season (December to

April) but the last five years have been difficult, with recurring drought, insect and

worm invasion, and floods all of which greatly affected staple food production.

Households depend on pension grants, child welfare, remittance, and other grants or

in-kind receipts as an important source of income to ensure staple foods for household

members, such as maize meal, mahangu (millet) meal, wheat flour, oil and sugar.

4Central Bureau of Statistics (2003). 2001 Population and Housing Census. National Report. Basic Analysis with Highlights. National Planning Commission, Republic of Namibia.

6


Some of these industrial products are fortified with vitamin A, thiamine, riboflavin,

niacin, iron and folic acid, though there are no guidelines for external controls to

assess independently the quality of the final product. Added to the issue of

accessibility of fortified staple foods, home gardening activities to increase the

production and intake of vitamin- and mineral-rich foods have not yet achieved

popular success due to important land property and water issues that prevent

continuous activities in groups or on an individual basis.

Emergencies occur when the population is exposed to risk factors. During disasters the

risk is higher for certain diseases. In emergencies (epidemics/disasters), the population

can be exposed to poor water supply and sanitation facilities, contaminated foodstuffs,

inadequate disposal arrangements for solid and hospital waste, and poor sewerage

systems, all of which can contribute to high malnutrition levels in Namibia.

In recent years the country has experienced a number of emergencies that have had

profound impacts on the health and nutrition of the population. The emergence of the

H1N1 pandemic in 2009 has added to the potential health risks faced by the country

due to natural disasters such as recurrent floods and drought, and disease outbreaks

(notably measles and meningococcal meningitis).

Namibia has a relatively efficient surveillance and emergency preparedness and

response system. However, there are challenges such as tardy and incomplete

reporting of cases, and the non-functioning of health emergency management

committees (HEMC) at various levels, as well as the lack of disease-specific epidemic

thresholds. In 2011, more than 130,000 people were affected by floods in the six

northern and north-eastern regions of Oshana, Ohangwena, Omusati, Oshikoto,

Kavango and Caprivi, which aggravated the nutrition challenges in the country.

1.3 HEALTH SERVICES IN NAMIBIA

The MoHSS is the institution primarily responsible for the provision of comprehensive

health services, including promotive, preventive, curative and rehabilitative care.

These functions are executed through the various national directorates, regional

health directorates, and district hospitals, which oversee the implementation of

health care delivery in their respective catchment areas.

‘Primary health care’ (PHC) is the guiding principle for the delivery of health services in

Namibia. PHC guidelines were developed in 1992 as an instrument for the delivery of health

services in Namibia. Various programme-specific policies and strategies were also

developed to complement the primary health care interventions in the country.

Namibia has a four-tier health delivery system:

First level: clinics and health centres;

Second level: district hospitals;

Third level: intermediate referral hospitals; and

Fourth level: central (national) referral hospitals.

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There are regional management teams (RMTs) responsible for all PHC and Directorate

of Special Programming (DSP) functions in the regions. Two chief health programme

administrators (CHPAs) and two senior health programme administrators (SHPAs) in

every region are responsible for the implementation and management of PHC and DSP

functions.

There are 34 health district coordinating committees (DCCs) responsible for the

implementation and management of all PHC and DSP functions. Although the need for

effective structures to implement PHC interventions at community level was

identified as early as 1992, The Official Primary Health Care/Community Based

Health Care Guidelines delineate no formal structures for health workers at

community level.

Access to health care is unevenly distributed; due to the vastness of the country

around 21 per cent of the population live more than 10 km from a health facility and

have to travel long distances to access basic primary health care.

The human resources for health at the lower level of the health care delivery system

(clinics) are not adequately equipped with various essential skills, e.g., life-saving

skills to handle emergency obstetric and neonatal care services; maternal and infant

nutrition; knowledge of the Integrated Management of Newborn and Childhood

Illnesses (IMNCI) programme; and especially early initiation of breastfeeding. In

addition, a shortage of skilled service providers, particularly doctors and

anaesthetists, creates a bottleneck because tertiary medical training in country only

started in 2010.

Other challenges emanating from the community include harmful socio-cultural

beliefs and practices; the limited number of community-based workers; poor male

involvement in sexual and reproductive health and nutrition; and poor socio-economic

status, among others.

Currently, the MoHSS is undergoing restructuring to respond to the health

developments and challenges of the 21st century. In addition, the PHC guidelines are

under revision to incorporate latest developments in health and nutrition in the

context of the double burden of communicable and non-communicable diseases and

other related issues (such as social services and rehabilitation).

1.4 NUTRITION SERVICES IN NAMIBIA

At national level, the nutrition programme is administered by the Food and Nutrition

Subdivision (FNS) of the Family Health Division (FHD) in the Directorate of PHC

Services at the MoHSS. The mandate of the FNS is to plan, implement, monitor and

evaluate food and nutrition activities.

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The Food and Nutrition Subdivision has the following functions and responsibilities:

To plan, implement, monitor and evaluate food and nutrition activities;

To coordinate national activities (supervision, monitoring and technical backstopping);

To coordinate capacity development;

To develop policies, guidelines and protocols;

To set the operational research agenda, coordinate national-level surveys, and analyse

and report on routine surveillance data;

To coordinate social mobilisation;

To coordinate community involvement; and

To collaborate with other stakeholders in nutrition.

The FNS is staffed by four programme officers; only one is a nutritionist (with the

designation of CHPA) and is head of the subdivision. Programme activities for nutrition

surveillance; maternal, infant and child nutrition promotion; HIV and nutrition; non-

communicable diet-related diseases; and micronutrient deficiency control are

managed by three senior health programme administrators (SHPAs). The three SHPAs

have nursing qualifications but no formal qualifications in nutrition. However they

have received shorter-term training in nutrition in subjects such as HIV and nutrition,

growth monitoring and promotion, infant and maternal nutrition, etc. Opportunities

are provided for staff members to attend conferences and nutrition-sensitive meetings

internationally. In addition, there are three nutritionists supported by development

partners’ funding to assist the subdivision, one based at FNS and two assistant

nutritionists attached to the regional health training centres.

At regional and district levels, medical officers and nurses are the key health

personnel providing nutrition services. Medical officers undergo a five-year

undergraduate training in a recognised university, leading to a Bachelor’s degree in

general medicine and general surgery. The training includes a component in nutrition,

which includes principles of nutrition, public health nutrition, and clinical nutrition.

Those who undertake postgraduate training in public health, such as the Master of

Public Health, also receive nutrition training.

Nutrition is also covered in the nursing training curriculum, but not sufficiently. Therefore

more in-service training in aspects such as infant and young child feeding, general nutrition,

and clinical management of malnutrition is given at service delivery and community levels.

However, there are no nutritionists at regional level, where nutrition activities are

currently integrated into the responsibilities of both CHPAs and two SHPAs responsible

for PHC and DSP functions in every region. Regional health administrators are

currently overloaded, and as a result nutrition activities are compromised. In

addition, there are no nutritionists at district level to support evidence-based

nutrition interventions in the community.

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1.5 HEALTH STATUS INDICATORS

According to the MoHSS National Demographic and Health Survey (NDHS) of 2006,

Namibia’s maternal mortality ratio (MMR) is at 449/100,000 live births, an increase

from 225/100,000 live births in 1992. The increase in maternal mortality over the

years is partially attributed to the high prevalence of HIV/AIDS in Namibia. The major

direct causes of maternal mortality are eclampsia (33 per cent), haemorrhage (25 per

cent), and obstructed labour (25 per cent); HIV/AIDS is the leading indirect cause of

maternal mortality, accounting for a significant proportion of all deaths. Evidence

shows us that anaemic women have a higher chance of dying from bleeding during

pregnancy, childbirth and the postpartum period as compared to those who have an

acceptable standard of haemoglobin.

The antenatal care (ANC) coverage for at least one visit is 95 per cent. Seventy per

cent of women attend ANC four times during their pregnancy; 81.4 per cent of

pregnant women deliver in health facilities and postnatal coverage is 78 per cent. The

contraceptive prevalence rate (CPR) is 46 per cent and unmet need for family

planning is three per cent. The NDHS 2006 shows that the teenage pregnancy rate has

decreased from 18 per cent in 2000 to 15 per cent in 2006, but still remains a

challenge as maternal and neonatal mortality is more common among teenage

pregnant women than among those who are 20 years and above.

Research indicates that widespread gender-based violence has implications for sexual

reproductive and child health. According to the MoHSS records in 2009, 1,039 rape

cases and 10,053 grievous bodily harm cases were reported to the Women and Child

Protection Units. Women and girls are mostly the victims, while the majority of

perpetrators are males and are known to the victims usually as family members,

spouses and partners. Women and girls who are exposed to gender-based violence are

more likely to have less/no control over their sexual and reproductive health. This

results in unwanted pregnancies through rape, non-use of family planning, teenage

pregnancy, poor maternal health, sexually transmitted infection (STIs) including HIV,

and death.

The HIV sero-prevalence among pregnant women attending ANC in 2010 was 18.8 per

cent. The total number of pregnant women in need of prevention of mother-to-child

transmission (PMTCT) services was 12,700. Namibia has adopted the new 2010 WHO

guidelines: Antiretroviral drugs for treating pregnant women and preventing HIV

infection in infants. Recommendations for a public health approach and has chosen

option B+, which will put HIV+ pregnant women on lifelong antiretroviral (ARV)

treatment once diagnosed. Exclusive breastfeeding for the first six months of life is

recommended for all infants regardless of HIV exposure or infection. Complementary

feeding is recommended to start at six months. At one year of life, HIV-exposed

infants should wean from breastfeeding. HIV-infected infants, as well as infants born

to HIV-uninfected mothers, should continue breastfeeding until two years and beyond,

if no other adequate nutritious diet can be provided.

A total of 314 health facilities out of 344 are providing PMTCT services, giving a

coverage of 92 per cent .Out of the total of 61,981 pregnant women who attended

10


ANC in 2009, 58,882 (95 per cent) received HIV counselling and testing services. At

labour and delivery, 85 per cent of HIV-positive women and 91 per cent of exposed

infants received ARV prophylaxis. The HIV positivity of exposed infants diagnosed using

the dioxyribo-nucleic acid polymerase chain reaction (DNA-PCR) technique has reduced

from 13.4 per cent in 2006/7 to 7 per cent in 2008/9. Continued challenges exist with

quality of care, continued follow-up of HIV-exposed infants, and reaching all women who

need ARV prophylaxis and treatment for themselves. There are also efforts to improve

male involvement in PMTCT, which has traditionally remained very low over the years.

Globally, approximately 70 per cent of childhood deaths are due to only five

conditions: diarrhoea, measles, pneumonia, malnutrition, and malaria. The situation

is similar in Namibia where HIV/AIDS, pneumonia, diarrhoea, malaria and malnutrition

are the main causes of mortality. The under-five mortality rate (U5MR) is 69/1,000

live births and there was a slight upward trend in infant mortality rate (IMR) and U5MR

in 2006/2007, as compared to 2000/2001 (IMR from 38/1,000 in 2000/1 to 46/1,000 in

2006/7, and U5MR from 62/1,000 in 2000/1 to 69/1,000 in 2006/7 respectively).

In order to address the high morbidity and mortality among children, the government

has adopted the Integrated Management of Newborn and Childhood Illnesses (IMNCI)

programme as a strategy to reduce newborn and child mortality in the country. The

first phase of IMNCI implementation took place in 1997 with support from major

partners, professional groups and other stakeholders in the country. National

immunization days (NIDs) were introduced in 1996 to accelerate progress towards the

attainment of a polio- and measles-free Namibia. In 2008, the MoHSS introduced the

‘Reach Every District’ (RED) approach to reach every child in every district with

immunization to improve routine immunization coverage. In 2011, penta-valent

vaccine (DPT-Hep-B-Hib-3) was introduced and the coverage for 2011 was 83 per cent.

1.6 HEALTH FINANCING IN NAMIBIA

Namibia allocates 12 per cent of its national budget to health. However there is no

specific budget line item for nutrition. Resources are pooled together for primary

health care programmes and the FNS has to compete for resources that are usually not

adequate to cater for implementation of all planned activities in a year.

1.7 NAMIBIA: THE FIGHT AGAINST MALNUTRITION

1.7.1 History of global commitment:

During the International Conference on Nutrition (ICN) 1992, governments (including

Namibia) pledged to make all efforts to eliminate or reduce substantially before the

next millennium: starvation and famine; widespread chronic hunger; under-nutrition

(especially among children, women and the aged); micronutrient deficiencies

(especially iron, iodine and vitamin A deficiencies); diet-related communicable and

non-communicable diseases; impediments to optimal breastfeeding; and inadequate

sanitation, poor hygiene and unsafe drinking water.

The World Health Assembly, the highest governing body of the WHO, has passed

several resolutions in the area of nutrition that include those on: infant and young

11


child feeding (IYCF); elimination of micronutrient deficiency; improving maternal

nutrition; and prevention of non-communicable diseases, among others e.g., the 45th

World Health Assembly adopted and endorsed the ‘Innocenti Declaration on Infant and

Young Child Feeding (IYCF)’.

Namibia adopted the Innocenti Declaration at the WHO/UNICEF policymakers' Meeting on

Breastfeeding in 1990. The meeting declared that as a global goal for optimal maternal

and child health and nutrition, all women should be enabled to practice exclusive

breastfeeding and all infants should be fed exclusively on breast milk from birth up to six

months of age. Thereafter, children should continue to be breastfed while receiving

appropriate and adequate complementary foods for up to two years of age or beyond.

This child-feeding ideal is to be achieved by creating an appropriate environment of

awareness and support so that women can breastfeed as recommended.

On 20 September 2011, President Hifikepunye Pohamba, speaking at the United Nations

(UN) General Assembly High Level Meeting in New York on the Prevention and Control of

NCDs, called for acceleration actions to address the risk factors contributing to NCDs.

In terms of demonstrating a tangible commitment for scaling up nutrition and health,

the ‘Abuja Declaration’ in 2001 emphasised that countries should allocate 15 per cent

of their government’s budget to health. Namibia has made progress in this regard and

is currently allocating 12 per cent of its national budget to health.

The policy and institutional changes for accelerating nutrition improvements need to

have sufficient political support to be adopted and implemented. In addition,

successful operations for delivering technical assistance depend largely on the

capacity of the international nutrition system to work with governments to assess and

build a broader ownership, as a prerequisite for policy change.

1.7.2 History of Namibia’s commitment: the national Food

Security and Nutrition Project (FSNP)

The national Food Security and Nutrition Project (FSNP) was established in 1991. The

long term goal of the FSNP is that: ‘All people in Namibia at all times, have physical,

economic and social access to sufficient, safe and nutritious food to meet their

dietary needs and food preferences for an active and healthy life’. The FSNP was

based on the following four pillars:

1. The first pillar of food availability was aimed at ensuring that a sufficient quantity of

food of appropriate quality is available to all people in Namibia through domestic

production and imports.

2. The second pillar of food access aimed at ensuring access by all individuals in Namibia

to adequate resources (entitlements) to acquire appropriate foods for a nutritious diet.

Entitlements include legal, political, economic and social arrangements.

3. The third pillar of food utilisation and nutritional requirements was to ensure that all

individuals in Namibia reach a state of nutritional wellbeing for which all physiological

needs are met.

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4. The fourth pillar of food security was stability in equitable food provision to ensure

that all people in Namibia have access to adequate food at all times.

The FSNP was devised under the rational of the ‘right to food of every person’. The

right to food is the right to have regular access to sufficient, nutritionally-adequate

and culturally-acceptable food for an active, healthy life. It is the right to feed

oneself in dignity, rather than the right to be fed. With many people still deprived of

enough food, the right to food is not just economically, morally and politically

imperative it is also a legal obligation. In Namibia, a large proportion of the

population is being faced with the impacts of drought, HIV/AIDS, and declining

agricultural productivity. Under these conditions, ensuring food security at all levels is

a difficult and complex matter, and requires collective action. A comprehensive and

conducive national programme for food security would contribute to providing an

environment in which food security issues can be discussed and acted upon by all

stakeholders.

The FSNP was intended to operate through a three-phased approach, namely: an

assessment and planning phase (Phase 1), a pilot implementation phase (Phase 2), and

an expansion phase (Phase 3).

Phase I was undertaken between 1991 and 1995. The activities were funded by the

Government of Norway and involved the preparation of the Food and Nutrition Policy

for Namibia (commonly referred to using the acronym NFNP) and the National Food

Security and Nutrition Action Plan (commonly referred to using the acronym FSNAP)

to address food security and nutritional issues. (The policy will be elaborated on later

in this document.)

Phase 2 was undertaken between 1997 and 2000. This was the pilot implementation

phase which was funded by the Government of Namibia (GRN) and focused on

institution building; human resources development; decentralisation of food security

and nutrition initiatives to four pilot regions; provision of assistance to develop action

plans; and the development of household food security and malnutrition information,

and monitoring and evaluation systems.

During this time, the period 1993-2002 was declared as the first ‘food and nutrition

decade’. This created an opportunity for food and nutrition security to be a

government-wide effort, leading to the creation of the Food Security and Nutrition

Secretariat to work closely with all relevant line ministries to assure that food security

and nutrition were included in every sector’s agenda.

To further enforce the food and nutrition agenda, cabinet instructed that a separate

multi-sectoral food security and nutrition chapter be included in the first National

Development Plan (NDP1) 1995-2000, to clearly indicate government’s commitment to

addressing issues of food insecurity and malnutrition in Namibia. The chapter was

prepared under the auspices of the Food Security and Nutrition Technical Committee

and its contribution was to review progress made since Independence to address food

security and nutrition-related issues, as well as to estimate national goals and

objectives within the context of improved food security and nutrition.

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A second food and nutrition decade’ (2003-2012) was announced by the President of

Namibia during the 2002 World Food Day celebrations. The declaration supported the

long-term national FSNP in Namibia.

Phase 3 was the final phase, which involved the expansion of the FSNP and formed

part of the second food and nutrition decade. This phase ran for six years (2000-2006),

with the aim of replicating the lessons learnt during the pilot phase on a larger scale

in areas of similar climatic, environmental, and ecological circumstances and

strengthening of the capacity of the cross-sectoral institutional framework to

coordinate and promote multidisciplinary food security and nutrition throughout the

country.

1.7.3 The Namibia Alliance for Improved Nutrition (NAFIN)

Namibia’s commitment to nutrition at the highest political level continued with the

establishment of the Namibia Alliance for Improved Nutrition (NAFIN) in 2009, and was

followed by a formalisation of the Alliance in 2010 through Cabinet Decision No.

17th/23.11.10/001, Establishment of a National Alliance for Improved Nutrition.

NAFIN is headed by the Prime Minister of Namibia, the Rt. Hon. Nahas Angula.

NAFIN was created as a platform to bring together key partners for a concerted

response in addressing the problem of malnutrition, expanding beyond the earlier

scope of the FSNC (which encompassed only the public sector). This platform aims to

provide a mechanism that ensures government stewardship responsibilities in nutrition

are consistent, coordinated and collaborative. In addition, private sector engagement

is called upon through public-private partnerships, with additional technical and

financial support from UN agencies and other development partners. This platform

additionally gives space for the active participation of civil society organisations,

faith-based organisations and nongovernmental organisations. The ultimate aim of the

platform is to provide a means of harnessing broad commitments of all jurisdictions to

evidence-based nutrition objectives.

The general objective of NAFIN is to develop and coordinate the implementation of a

multi-sectoral national nutrition strategy and to strategically manage national

nutrition promotion activities. In overseeing the development and implementation of

a multi-sectoral national nutrition strategy, NAFIN will focus on four key actions and

employ five main strategies in meeting its broad objectives.

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The areas of focus for NAFIN are:

1. Reducing malnutrition and promoting good nutrition for all Namibians, with a focus on

women and children.

2. Capacity development for service delivery across key government sectors such as

agriculture, health, education, and gender and child welfare to ensure and prioritise

essential nutrition and household food security for vulnerable disadvantaged

households and communities.

3. Ensuring the economic and social benefits of nutrition security are reflected in sectoral

plans and policies as well as the national development plans.

4. Preventing and reducing overweight and obesity.

The five main strategies that NAFIN plans to employ to reach its objectives are:

1. The Alliance supports action to develop, coordinate and monitor an integrated national

nutrition strategy and action plan as part of the National Development Plan and Vision

2030.

2. The Alliance has a leadership role in building a common approach to nutrition across

the sectors and levels of government.

3. The Alliance provides expert advice on nutrition issues from a multi- and cross-sectoral

perspective to the cabinet, parliament and individual government ministries and

agencies.

4. The Alliance promotes better communication. Using its networks it serves as a resource

available to government at all levels, and to health and nutrition professions, industry,

and other stakeholders for sharing and disseminating information about nutrition.

5. The Alliance fosters partnerships working with public, non-government and private

sectors to advance nutrition in Namibia.

The actions to be explored by NAFIN that emerged out of the five proposed strategies

are listed below:

1. Making fortification work better;

2. Prioritising the needs of infants and young children;

3. Promoting advocacy and awareness;

4. Creating institutional and vulnerable group feeding programmes;

5. Technical innovation and capacity development;

6. Identification of a ‘minimum food basket’.

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Following on from the cabinet decision that established NAFIN, a document presented

during the formal launch of NAFIN was used a basis to inform a set of cabinet decisions

to support and expedite nutrition actions in Namibia. This cabinet decision entitled

Report on Malnutrition in Namibia: The Time to Act is Now (Cabinet Decision No.

3rd/01.03.11/004), was released in March 2011. This cabinet decision resolved eight

core resolutions and five additional resolutions.

The five core resolutions covered recommendations on: fortification; agricultural

biofortification; targeted feeding programmes and food distribution for vulnerable

sections of the population and, as part of emergency responses, increased awareness

programmes and advocacy actions to improve community awareness and therefore

action; community-based growth monitoring programmes; and nationwide deworming,

immunization and supplementation campaigns.

The five additional resolutions recommended: that accountability be pegged to the

Office of the Prime Minister (OPM) and/or the respective line ministries; the

involvement of regional councils in the implementation of the recommended actions;

curriculum modification to strengthen the teaching of nutrition and related subjects;

linkages be made between food distribution and food production initiatives; as well as

the inclusion of the national youth services in food distribution. In summation, these

recommendations supported a multi-sectoral, multi-institutional response to existing

and scaled up nutrition activities.

A third set of multi-sectoral nutrition-sensitive and specific cabinet resolutions were

released under the leadership of the OPM in August 2011, under Cabinet Decision

No.14th/16.08.11/003, entitled Report on the National Vulnerability Assessment

2010/2011. This set of cabinet decisions encompassed recommendations to the

Disaster Risk Management Team, which is a directorate within the OPM, and called

upon joint actions within the education, health, rural development, environment and

tourism, and agricultural sectors, and special projects under the OPM.

An additional demonstration of political commitment was strongly communicated

when all 13 governors from the regions in Namibia met in Windhoek in August 2011, at

the invitation of the Chair of NAFIN, the Rt. Hon Prime Minister Nahas Angula. The

purpose of the meeting was to create awareness about the nutrition situation in the

country and all the respective regions.

The governors were galvanised into action having learned more about the importance

of nutrition to the development of the nation and in their specific regions, and a key

output from the meeting was the ‘Declaration of Commitment’ signed by all 13

regional governors. In this declaration, the governors pledged to support the prime

minister in initiatives to scale up nutrition, and to act as regional representatives for

NAFIN which resonates with the initial spirit of the national Food Security and

Nutrition Council.

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Additionally, the governors pledged to mobilise communities and community leaders

as part of bi-annual national immunization days, as well as in breastfeeding

campaigns, dietary diversification efforts, maternal nutrition activities, and water and

sanitation activities. The governors also pledged to support food distribution efforts

among vulnerable groups and school feeding efforts, and in so doing promote and

support local food production.

1.7.4 The Scaling Up Nutrition (SUN) movement – Namibia

membership

In November 2011, Namibia was accepted as the 25th country to join the Scaling Up

Nutrition movement. In February of 2012, the prime minister, as the Chair of NAFIN,

was chosen to be part of a high level group known as the Lead Group, comprising

heads of state, prime ministers, ministers of finance, and heads of international

organisations. In joining the SUN movement, Namibia will be required to fulfil certain

requirements, which include identifying a government focal point, establishing a lead

donor partner, undertaking a situation assessment, and identifying a country

representative to take part in the SUN Country Partner Reference Group. In this

respect, Namibia has shown her commitment to the process having identified a lead

donor partner, undertaken the Namibia NLSA survey, and nominated a country

representative to take part in the SUN Country Partner Reference Group.

1.8 DEVELOPMENT OF PLANS, POLICIES AND GUIDELINES

TO FIGHT MALNUTRITION

1.8.1 The ‘National Food and Nutrition Policy’ (NFNP)

In 1995, the Food and Nutrition Policy for Namibia (usually referred to as the

‘National Food and Nutrition Policy’, NFNP) was developed. The NFNP provides the

necessary framework and guidelines for actively addressing the problems of food

insecurity and malnutrition in Namibia over the medium to long-term, with the overall

objectives to:

1. Improve the quantity and quality of food consumed by the population with the aim of

ensuring an adequate diet for all;

2. Empower households to use the resources available to them to improve childcare,

feeding practices, and their environmental sanitation; and

3. Provide an adequate level of social and supporting services.

These three areas establish the agenda for the initiatives that are necessary for the

achievement of the required food security and nutrition outcomes. These objectives

are supposed to be achieved through strategies and programmes designed in

accordance with other basic government principles:

To maximise popular participation in the development process by emphasising

communities’ participation in solving their own food security and nutrition problems;

17


To decentralise activities and decision making to respond to the high level of regional

differentiation ;

To educate and sensitize people concerning food and nutrition issues;

To create awareness in all parts of the government and community structures of the

importance of nutrition issues and their cross-sectoral nature; and

To reduce individual and community dependence on government and other central

structures to solve food and nutrition problems.

This policy is still active, but the MoHSS is in the process of developing a ‘Sexual

Reproductive, Child Health and Nutrition Policy’, which will replace all other

programme policies. Nutrition is integrated within this policy with the goal of reducing

the level of malnutrition and improving IYCF practices in line with the global, regional

and national guidelines.

The policy includes the following nutrition policy statements:

All health facilities shall provide growth monitoring to all children under five years of

age, both in the health facilities and at outreach points.

Facility- and community-based therapeutic feeding shall be provided to all severely

malnourished children to alleviate the consequences of malnutrition.

Supplementary feeding shall be provided to moderately malnourished children,

pregnant, and lactating women.

Micronutrient deficiency shall be prevented and treated through routine health facility

supplementation and campaigns.

Exclusive breastfeeding for six months shall be promoted to all infants irrespective of

the HIV status of women, as long as the proper ARV prophylaxis for the mother and the

newborn is provided.

1.8.2 The National Food Security and Nutrition Action Plan

(1995)

The 1995 National Food Security and Nutrition Action Plan (FSNAP) was prepared in

response to deteriorating conditions of food security and nutrition in many urban and

rural parts of Namibia. The FSNAP is major tool for the implementation of the NFNP.

The FSNAP outlines existing government, NGO, and private sector programmes and

initiatives addressing food and nutrition issues and proposes a comprehensive set of

mutually supportive, cross-sectoral, broad-based actions to fill the identified gaps in

the existing programmes and to help achieve government’s food security and

nutrition-related goals and objectives. It also provides a detailed strategic framework

for the implementation of government’s food and nutrition policies.

The plan was intended to provide the government and key partners with clearly-

defined project profiles that could be used for motivating for funding support, and

whose implementation could endeavour to ensure that every Namibian has access to

sufficient, safe and nutritious food to meet dietary needs for an active life.

18


The Food and Nutrition Guidelines for Namibia document was published in 2000. The

aim of the guidelines was to help the public develop and practice healthy eating

habits. The guidelines were developed as a collaboration between the MoHSS, FAO,

WHO, UNICEF, the Ministry of Agriculture, Water and Rural Development, the Ministry

of Basic Education and Culture, and the University of Namibia. The Food and Nutrition

Guidelines for Namibia promote the consumption of a wide variety of culturally-

acceptable healthy foods. Healthy diets help to correct bad eating habits and

reinforce good eating habits, thus helping to maintain good health.

1.8.3 The National Strategic Plan for Nutrition (2011-2015)

The National Strategic Plan for Nutrition (2011-2015) (NSPN) was initiated by the

Directorate of Primary Health Care Services of the MoHSS as a response to global and

local calls to action, as well as renewed political commitment in Namibia and

strategic direction within the MoHSS. The resulting five-year plan aims to re-

emphasise the crucial role nutrition plays in the health and productivity of the nation,

and improved quality of life for all. As such, it is a vital building block in the efforts to

achieve Namibia’s MDGs. It provides a framework for interventions and activities at

national, regional, district and community level, with considerable collaboration

required from multilateral and bilateral development agencies, other line ministries,

civil society organisations (CSOs), and private institutions.

The NSPN specific objectives, initiatives and indicators, and a detailed action plan,

have been developed for each strategic priority:

1. Maternal and child nutrition

2. Micronutrient deficiencies

3. Diet-related diseases and lifestyles

4. Nutritional management of communicable diseases

1.9 NUTRITION-SPECIFIC AND SENSITIVE POLICIES AND

LEGISLATION

Policies and legislations are critical steps in a strategic response to maternal and child

under-nutrition. In this respect, it is important to distinguish between nutrition-

specific and nutrition-sensitive instruments. Nutrition-specific instruments directly

influence nutrition outcomes, e.g., infant and young child feeding guidelines.

Nutrition-sensitive instruments indirectly influence nutrition outcomes, e.g., water

and sanitation policy or agricultural policy, or school health policy. These in turn need

to be translated into action plans and guidelines that can be used on the ground.

Table 1, below, outlines nutrition-specific instruments and nutrition-sensitive

instruments.

Table 1: National policies, guidelines and other documents related to nutrition-specific and

nutrition-sensitive actions

19


Nutrition-specific policies/guidelines/documents

Policy/guideline/document Coordinating body Date

National Declaration on Food and Nutrition National Food Security and Nutrition Council

1995

Food and Nutrition Policy for Namibia National Food Security and Nutrition Council

1995

Prevention, Control and Treatment of Vitamin A Deficiency

Ministry of Health and Social Services 1999

The Prevention and Care of Malnourished Children in our Communities and at Health Facilities


Guidelines on How to Use the Child Growth Card to Promote Growth


Food and Nutrition Guidelines for Namibia National Food Security and Nutrition Council

2000

National Policy on Infant and Young Child Feeding Ministry of Health and Social Services 2003

Regional Food Security and Nutrition Action Plans Ministry of Regional and Local Government, Housing and Rural Development

2006

Nutrition Management for People Living with HIV/AIDS Guidelines


Guidelines for the Prevention of Mother-to-Child Transmission of HIV (Second Edition)


Nutrition Assessment Counselling and Support for PLHIV. Operational Guidelines


National Strategic Plan for Nutrition Ministry of Health and Social Services 2011

National Guidelines on Infant and Young Child Feeding


Report on the National Vulnerability Assessment 2010/2011

Office of the President 2011

Establishment of a National Alliance for Improved Nutrition


Report on Malnutrition in Namibia: the time to act is now!


20


Nutrition-sensitive policies/guidelines/documents

Policy/guidelines/documents Coordinating body Date

Agriculture and food security

National Agricultural Policy Ministry of Agriculture, Water and Rural Development

1995

National Horticulture Development Initiative Ministry of Agriculture, Water and Rural Development and NAB Horticulture

2002

Green Scheme Policy Ministry of Agriculture, Water and Forestry

2008

National Water Supply and Sanitation Policy Ministry of Agriculture, Water and Forestry

2008

Poverty reduction and development

National Development Plan (NDP1) 1995-2000 National Planning Commission 1995




Public health

National Policy for Reproductive Health Ministry of Health and Social Services 2001

National Health Emergency Preparedness and Response Plan


National Policy on HIV/AIDS Ministry of Health and Social Services 2007

National Sanitation Strategy 2010/11-2014/15 Ministry of Agriculture, Water and Forestry

2009

National Strategic Framework for HIV and AIDS Response

Republic of Namibia 2010

National Health Policy Framework 2010-2020. Towards quality health and social welfare services


National Community Home-Based Care Standards Ministry of Health and Social Services 2010

Education

National Policy for School Health Ministry of Health and Social Services 2008

Social protection

National Policy on Orphans and Vulnerable Children Ministry of Women Affairs and Child Welfare

2004

National Integrated Early Childhood Development Policy

Ministry of Gender Equality and Child Welfare

2007

National Agenda for Children 2012-2016 Ministry of Gender Equality and Child Welfare

2012

Partnerships

Civic Organisations Partnership Policy National Planning Commission 2005

21


Table 2: Legislation enacted to support nutrition activities

Nutrition-relevant laws

Law Date

Salt Iodization Legislation No 883 1994

Social Security Act, 1994 (Amended) 2004

Water Resources Management Act 2004

Maternity Protection Law (12 weeks) 2007

Public and Environmental Health Bill (including the International Code of the Marketing on Breast Milk Substitutes: drafted measures awaiting enactment)

Expected: 2012

Flour fortification to prevent and control micronutrient deficiencies

Namibia does not yet have legislation on fortification, but is working towards this

achievement through the setting up of a food fortification technical working group

under the NAFIN umbrella. Currently, flour millers enrich flour on a voluntary basis

using South African fortification guidelines.

1.10 GLOBAL MALNUTRITION SITUATION

Malnutrition remains a major contributing factor to child mortality. About one-third of

all child deaths in 2011 were linked to malnutrition globally (UNICEF 2011). Nearly

one-third of children in the developing world are either underweight or stunted, and

more than 30 percent of the developing world’s population suffers from micronutrient

deficiencies (State of the World’s Children, UNICEF 2012)

Unless policies and priorities are changed, the magnitude of the problem will prevent

many countries from reaching every mother and child through scaling up nutrition

interventions in order to achieve their Millennium Development Goals (MDGs).

All children have the right and the same potential to grow and develop. Although

under-nutrition can be rapidly eliminated if adequate maternal and child nutrition is

ensured, 29 per cent of children in developing countries (or 171 million children under

five years of age) are too short for their age. Current global rates of progress, while

positive, are insufficient to meet MDG1, Target 1C; in fact the rates of progress need

to be more than doubled in order to achieve this MDG. Furthermore, not achieving the

under-nutrition target will negatively impact on all other MDGs.

1.11 OVERVIEW OF THE NUTRITION SITUATION IN NAMIBIA

Malnutrition remains a public health problem in Namibia. The table below indicates

the magnitude of the nutritional problems among children in Namibia.

22


Table 3: Magnitude of nutritional problems among children in Namibia

Estimated total number of children under five

years of age = 291,757

Percentage Number

Stunted (low height for age) 29 per cent 84,610

Underweight (low weight for age) 17 per cent 49,599

Wasted (low weight for height) 8 per cent 23,340

Source: National Planning Commission (2010) and NDHS.

The general pattern indicates that regions with high levels of poverty, low literacy

rates, high HIV prevalence, and with predominantly rural populations, have the

highest levels of stunting for example Kavango, which has highest level of poverty

(50.4 per cent, low literacy level of 79 per cent, high teenage pregnancy rate of 34

per cent, and HIV sentinel prevalence of 10.4 per cent has the highest stunting rate

(39 per cent) (NDHS). Children born in the poorest and second poorest wealth quintile

households have a threefold risk of being stunted compared to those born in the

richest quintile (National Planning Commission 2008).

Slightly more than four per cent of the children were overweight or obese. This over-

nutrition was more present in urban settings (seven per cent vs. three per cent in

rural areas) and in wealthier households. According to the NDHS, the higher the

mothers' education level, the more prone the children are to being overweight or to

obesity, and children having an overweight or obese mother may also be more

susceptible to being overweight or to obesity.

The NDHS showed that 14 per cent of the infants less than six months old were

already stunted, 11 per cent were underweight, and 11 per cent were acutely

malnourished (while another 13 per cent were overweight or obese). Severe acute

malnutrition affected 4.4 per cent of infants, which is the highest proportion of

children under five years of age affected by severe acute malnutrition (SAM).This

serious situation could be linked with the confusing messages regarding breastfeeding

in the context of HIV and the use of infant formula that the population is receiving.

23


Figure 1: Regional prevalence of malnutrition among children under five years of age in Namibia

(NDHS 2006)

Only half of all Namibian babies are exclusively breastfed within the first two months

of life, and only 24 per cent of infants are exclusively breastfed for six months. In

addition, immediately following birth, over 14 per cent of Namibian newborn babies

receive pre-lacteal feeds. Bottle-feeding, non-breast milk feeds such as juices and

plain water, and complementary solid foods are introduced within the first three

months of infants’ lives. In Namibia, the number of bottle-fed babies exceeds the

number of exclusively breastfed babies at three months.

The emergence of HIV/AIDS has created a lot of confusion on issues of exclusive

breastfeeding. The frequent changes in guidelines in relation to HIV and infant

feeding, for example regarding the abrupt cessation of breastfeeding and provision of

formula feeding (without considering affordability, feasibility, safety and

sustainability) created confusion among managers and health workers. Based on the

above facts, Namibia revised the IYCF guidelines in line with the 2010 WHO

recommendations and guidelines on PMTCT. This will alleviate the confusion and

misunderstanding surrounding breastfeeding.

Regarding the nutrition situation in women aged 15 to 49 years, 6 per cent of them

were moderately or severely thin with a body mass index (BMI) under 17, and 10.2 per

cent were mildly thin with a BMI between 17 and 18.4. On the other hand, 16 per cent

of mothers were overweight with a BMI between 25 and 29 and 12 per cent were

obese with a BMI of > 30 and above. The comparison of overweight rate to the

24


underweight rate (28 per cent vs. 16 per cent, respectively) reflects the double

burden of over- and under-nutrition.5 This double burden of under-nutrition and over-

nutrition in Namibia highlights the current epidemiological and nutritional transition

as it is seen in many other African countries.6,7,8

Obesity is often seen as one of the main risk factors associated with the increased

rate of NCDs such as hypertension, diabetes, insulin resistance and hyperlipidemia. 9

This situation needs also to be addressed through healthy eating and promotion of

physical activity.

1.11.1 Over-nutrition and non-communicable diseases

Over-nutrition is the result of an excess consumption of energy-dense and

micronutrient-poor foods; this is physically manifested as overweight and obesity. The

diseases associated with overweight and obesity are diabetes, hyperlipidemia,

hypertension and other NCS such as cardiovascular diseases, cancer, osteoporosis,

asthma and dental diseases, among others.

NCDs, principally cardiovascular diseases, diabetes, cancers and chronic respiratory

diseases, are the leading causes of preventable morbidity and disability, and currently

cause over 60 per cent of global deaths, 80 per cent of which occur in developing

countries. By 2030, NCDs are estimated to contribute to 75 per cent of global deaths

(WHO 2011).

As mentioned above, the prevalence of overweight and obesity among women of

reproductive age group were 16 per cent and 12 per cent respectively. More than four

percent of children under five years of age were also found to be overweight or obese.

This situation was more prevalent in urban settings (seven percent) than in rural areas

(three percent), and in wealthier households. The NDHS report also shows that

overweight and obesity are associated with higher education levels, as well as the

highest wealth quintiles.

Health facility-based data indicate hypertension and diabetes as the first and second

causes of disability among adults respectively. From the MoHSS Health Information

System (HIS) reports, heart failure, hypertension and strokes collectively were

responsible for five per cent of all health facility deaths in 2005; the proportion of the

NCD deaths grew to six per cent in 2006 and eight per cent in 2007.

5Mendez, M.A., Monteiro, C.A. and Popkin, B.M. (2005) ‘Overweight exceeds underweight among women in most developing countries’. Am J ClinNutr, 2005; 81: 14-21.

6 Standing Committee on Nutrition (2006) Diet related chronic diseases and the double burden of malnutrition in West Africa. SCN New, 2006; Number 33.

7 Vorster, H.H., et al. (2005) ‘The nutrition and health transition in the North West Province of South Africa: a review of the THUSA (Transition and Health during Urbanisation of South Africans) study’. Pub Health Nutr, 2005; 8(5): 480-90.

8Popkin, B.M. (2004) ‘The Nutrition Transition: An overview of world patterns of change’. Nutr Rev., 2004; 62(7): S140-3.

9Popkin, B.M. and Gordon-Larsen, P. (2004) ‘The nutrition transition: worldwide obesity dynamics and their determinants’. Int J Obes, 2004; 28: S2-S9.

25


The prevalence of overweight, obesity and associated NCDs is of public health concern as

these are emerging as important causes of morbidity and mortality in Namibia. Namibia is

using standardised surveillance methods and rapid assessment tools such as the WHO

STEPwise approach to the surveillance of risk factors for non-communicable diseases.

1.11.2 Micronutrient deficiency situation

There are no actual micronutrient deficiency data on the adult population. The recent

information for children is focused on the coverage of routine vitamin A

supplementation and the availability of iodized salt at the household level. The

specific micronutrient deficiency data (iodine, vitamin A and iron) are 20 years old

In 1992, iodine deficiency disorders were identified as important public health

problem, with 55 per cent of severe prevalence of goitre in Caprivi Region and a

moderate prevalence (15-25 per cent) in north-west regions.10 Salt iodization became

mandatory in 1994 and a study conducted in the year 1998/9 found that the

prevalence of iodine deficiency as illustrated by the prevalence of goitre among

children was 0.2 per cent. However there were still nearly 13 per cent of households

which did not use iodized salt which could explain why 15 per cent of Namibian

children aged 8 to 12 years (21 per cent in rural settings and 9 per cent in urban

settings) still had severe iodine deficiency identified by their urinary iodine

concentration (<2µg/dl). The urinary iodine deficiency was more prevalent in Kavango

(47 per cent), where only 55 per cent of households had access to iodized salt.11 In the

2000 NDHS, it was reported that only 55 per cent of Namibia’s households were using

iodized salt. Some regions had much lower than the national average (16 per cent in

Omaheke and 31 per cent in Kavango regions).

In 1992, up to 23.5 per cent of pre-school children aged two to six years had either

severe or moderate vitamin A deficiency, with a serum retinol level of <20µg/dl. At

that time distribution of vitamin A capsules was not integrated into the Ministry of

Health and Social Services (MoHSS) action plan.12

Vitamin A supplementation is routinely given to all children at nine months and every

six months thereafter until the age of six years. Vitamin A supplementation is also

provided during the National Immunization Days. In 2000, the NDHS reported that only

38 per cent of children received vitamin A capsules and only 33 per cent of women

received vitamin A after delivery (postpartum). The coverage of vitamin A

supplementation was somewhat higher in 2006 (NDHS 2006) with 52 per cent of

children having received vitamin A capsule and 12 per cent iron supplements. The

coverage of deworming as a treatment among children was nine per cent according to

the NDHS 2006. Recently, deworming was adopted as a strategy to improve the

nutritional status of children in Namibia.

10Varghese P. (1994). Salt iodization in Namibia. MoHSS.

11Ministry of Health and Social Services, Republic of Namibia, (2001). Nation-wide Follow-up Survey on Iodine Deficiency Disorders (IDD) in Namibia, 1998/99.

12Ministry of Health and Social Services, Republic of Namibia (1999). Prevention, Control and Treatment of Vitamin A Deficiency Policy Guidelines.

26


The routine supplementation for women during pregnancy and after delivery showed

some improvement over the years. According to the results, 51 per cent of women

received vitamin A postpartum (33 per cent in 2000, NDHS) and 31 per cent took iron

supplements for more than 90 days. Night blindness without vision difficulty during

the day was reported by three per cent of women. Deworming during pregnancy is

uncommon (seven per cent).

The ferritin levels were found to be adequate for all children and the hypothesis that

this could be associated with the use of iron pots for cooking was raised but not

verified. The finding that revealed the adequate levels of ferritin among children

needs to be investigated further since it is commonly believed that iron-rich foods

could be available at the household level but not necessarily be accessible to children.

Soil-transmitted helminthes that can potentially aggravate iron-deficiency anaemia

are also prevalent in Namibia.

Even in malaria-prone areas, the ferritin level was adequate despite the low use of

mosquito nets by children (12 per cent) and women (eight per cent).13 In its national

nutrition action plan, Botswana reported that in 1994 the prevalence of anaemia was

38 per cent in children and 33 per cent in women, which seems contrary to Namibia's

findings when life and eating patterns are thought to be similar on many levels.14 This

issue brings questions regarding the quality of the sample collection and analysis that

cannot be answered.

Beside deficiency in iodine, vitamin A or iron, it is also important to look at the zinc status.

There are no nutritional data on zinc status in Namibia. However, diarrhoea rate, stunting,

and low intake of food rich in zinc are considered as proxy indicators of zinc deficiency.15,16

Nearly one third of children are stunted and more than ten per cent of children had

diarrhoea.17 The highest sources of zinc are animal products and it is known that

consumption of a low zinc bioavailable diet such as the consumption of a plant-

based diet (legumes and nuts, whole grains cereals, tubers) which contains phytates

limits zinc bioavailability. It is believed that animal products consumption is common

in the general food patterns but there are no data regarding the real quantity eaten

by children. Legumes and nuts are found traditionally in the country but consumption

is low. This information might suggest that zinc status should be analysed and

intensifying supplementation of zinc should be pursued.18

13Ministry of Health and Social Services (MoHSS) and Macro International Inc. (2008). Namibia Demographic and Health Survey 2006-07.

14Ministry of Health, Republic of Botswana (2005). National Plan of Action for Nutrition 2005-2010.

15 Gibson, R.S. (2007). Determining the risk of zinc deficiency: Assessment of dietary zinc intake. IZiNCG Technical Brief, No.3.

16Hotz, C. and Brown, K. H. (2004). ‘Assessment of the risk of zinc deficiency in populations and options for its control’. Food and Nutrition Bulletin, 2004;25(1 (suppl.2): p. S95-S203.

17Ministry of Health and Social Services (MoHSS) and Macro International Inc. (2008). Op. cit.

18 Hess et al. (2009). 'Recent Advances in Knowledge of Zinc Nutrition and Human Health' in Systemic Review of Zinc Intervention Strategies. Food and Nutrition Bulletin; 30 (1): S5-11.

27


Folic acid and niacin deficiencies are other micronutrient issues that need to be

investigated in Namibia. Folic acid deficiency is associated with increased risk of low

birth weight and neural tube defects. According to the NDHS (2006), 14 per cent of

babies had low birth weight (less than 2.5 kg). The MoHSS HIS indicated that in 2006,

out of an estimated 65,000 births reported, 239 were premature and 286 babies were

born with congenital malformations of the nervous system (including spina bifida).

These public health problems can be associated to folic acid deficiency, HIV,

alcoholism, or other health conditions which need to be investigated.

Pellagra is the clinical manifestation (dermatitis, diarrhoea and dementia) of a lack of

niacin (or tryptophan amino acid). This is seen in areas where maize is the main staple

food, with low intake of red meat. In Namibia, the porridge of thick paste made with

traditional maize flour may lack niacin and hence predispose people to pellagra.

Pellagra or niacin deficiency has been reported in the past and cases still are reported

on a regular basis but the national HIS does not elucidate on the magnitude of the

problem for informed programming and decision making.

1.11.3 Infant and young child feeding (IYCF)

Breastfeeding is common in Namibia, with 94 per cent of children being breastfed at

some point during their life. More than 70 per cent were breastfed in the hour

following birth and 92 per cent in the first day after birth. However, 14 per cent of

newborns received liquids other than breast milk in the first three days of life. Bottle-

feeding is common in Namibia (35 per cent in 0-5 months, 49 per cent in 6-9 months,

32 per cent in 12-23 months and 15 per cent in 24-35 months).These practices

contribute to the low prevalence of exclusive breastfeeding in Namibia. As shown in

Figure 2, below, exclusive breastfeeding is not common and other foods and liquids

were given to children before the age of six months. Figure 2 is a comparison between

2000 and 2006 data.

28


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-5 m 6-9 m

perc

enta

ge

2006/7 NDHS

Infant feeding practices by age in 2006/7 (NDHS)

complementary foods

other milk

non milk liquids/ juices

plain water only

not breastfeeding

exclusively breastfed

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-4 m 4-5 m 6-9 m

perc

enta

ge

NDHS 2000

Infant feeding practices by age in 2000 (NDHS)

complementary foods

other milk

non milk liquids/ juices

plain water only

not breastfeeding

exclusively breastfed

Figure 2: IYCF practices in Namibia in 2000 and 2006.

The NDHS has revealed that breastfed infants receive complementary food as early as

two months of age. Most breastfed and non-breastfed infants in the 6-23 month age

group received food made from grains (90 and 97 per cent respectively). In the same

age group only 39 per cent of breastfed infants and 43 per cent on non-breastfed

infants received fruits and vegetables rich in Vitamin A, and only 53 per cent of

breastfed infants and 73 per cent of non-breastfed infants reportedly received meat,

fish or poultry. This snapshot of dietary intakes suggests that complementary food

provided is not adequate.

29


As shown in Figure 3, below, only 70 per cent of infants 6-8 months of age receive

solid, semi-solid or soft foods, i.e., the timely introduction of appropriate

complementary foods. Furthermore, only 61 per cent of children 6-23 months of age

receive foods from four or more food groups; only 41 per cent of children received

complementary foods the minimum number of times or more as an indication of

sufficient energy intake from foods other than breast milk; and only 26 per cent of

children received a minimum acceptable diet apart from breast milk.

CF = complementary feeding; MDD = minimum dietary diversity; MAD = minimum adequate

diet; MMF = minimum meal frequency.

Figure 3: Timely and appropriate introduction of complementary food in Namibia

The compliance with international and national IYCF recommendations is weak and

highlights the importance in addressing the adequacy of the complementary food

offered.

1.11.4 Food intake patterns

Detailed data on common food intake patterns in Namibia are scarce. The staple foods

in Namibia are based on maize meal or mahangu (millet), which is prepared as

porridge or a thick paste with fish or meat sauce; few people consume legumes. Fruits

and vegetables are not commonly consumed, but some green vegetables and tomatoes

are added to flavour the staple food, meat or fish, but not on an everyday basis.

The challenges to adequate nutritional status in Namibia are due to limited access to

diverse diets rich in micronutrients. In general, the Namibian diet is heavily reliant on

cereal-based staples, especially maize (in the urban areas, as well as central and

south Namibia) and pearl millet (which is primarily consumed in the northern regions

of Namibia).

According to the food consumption survey that was undertaken in 1999, 75 per cent of

the population reported having breakfast; 72.8 per cent reported having lunch; and

30


97.8 per cent had an evening meal. In terms of perceived adequacy of food consumed,

60 per cent of respondents in the survey indicated that they had not had enough to

eat and 62.8 per cent reported that the household had difficulties accessing enough

food to meet their needs. (Southern Consultants Windhoek for the National Food

Security and Nutrition Technical Committee 2008.)

The diversity of Namibia’s socio-economic patterns, agro-ecological zones, and

traditions was reflected in food consumption patterns. Along agro-ecological zones it

was observed that populations in the south of the country were more reliant on food

purchases into the household, and primarily consumed meat and maize porridge. In

the north-west the diet consists of maize, meat and milk. In the north of the country,

where small-scale agriculture is practiced, households consumed maize porridge,

millet, sugar, oil, meat and milk. In the north-east, locally-gathered seasonal fruits

and vegetables as well as insects supplement the diet. In the north-east, freshwater

fishing supplements the primarily maize, millet and meat diet. However across the

board, wealthier households consumed more fruits, vegetables and animal-source

foods and were reliant on purchases of food into the household. (Southern Consultants

Windhoek for the National Food Security and Nutrition Technical Committee 2008.)

The food patterns are believed to be different between urban and rural areas. Food

diversity may be higher in urban areas, with shops and markets selling a variety of

fresh and processed food products. However, it is not known if their most vulnerable

households have access to this greater diversity. In rural areas, where an important

number of vulnerable households are found, the small local shops sell mainly basic

commodities (maize meal and mahangu meal, rice, pasta, cookies, margarine, oil,

salt, sugar and sugary products such as flavoured fruit beverages).

The NDHS data showed the quality of women's dietary intake. Foods made from grain

were eaten by 57 per cent of women; 25 per cent of women reported consuming roots

and tubers; and 18 per cent consumed legumes. Most women (71 per cent) ate meat,

fish, shellfish, poultry or eggs; 15 per cent ate cheese and yogurt; and 26 per cent

drank milk. Vitamin A-rich fruits and vegetables were consumed by 47 per cent of

women. 54 per cent of women consumed food items made with oil, fat or butter and

38 per cent consumed sugary foods. According to the NDHS, 83 per cent of women

consumed vitamin-A rich foods and 71 per cent iron rich foods.

1.12 NUTRITION IN DIFFICULT CIRCUMSTANCES

1.12.1 Nutrition in emergencies

Natural and manmade emergencies disrupt the socio-economic activities of the

Namibian communities affected and predispose the population to malnutrition. The

magnitude of the problem is worse among the vulnerable segments of the population

(women, children and the elderly) and predisposes them to higher morbidity and

mortality due to malnutrition.

31


The WHO has developed several health and nutrition assessment tools for use during

emergencies, and guidelines to implement effective interventions to avert deaths and

disabilities among the affected populations. The major nutritional deficiencies during

emergencies are protein-energy malnutrition and micronutrient deficiencies (which

include iron, iodine, vitamin A and others).

During emergencies, a general feeding ration is required when the population has no

access to sufficient food to meet the nutritional needs. The general ration should

meet the population’s minimum energy, protein, fat, and micronutrient requirements.

In addition, the general ration should be culturally acceptable, fit for human

consumption, and easily digestible for children and other affected vulnerable groups.

Namibia has been affected by repeated droughts and floods that affected a significant

proportion of the population during recent years. The GRN, through its Disaster Risk

Management Committee, has been able to address the disasters through the provision

of a food ration and supplementary and therapeutic feeding through MoHSS and other

partners as needed.

1.12.2 HIV and nutrition

According to the HIV sentinel surveillance data of 2010, 18.8 per cent of pregnant

women are HIV-positive. There is a wide discrepancy between different regions with

the infection rate reaching as high as 37 per cent in some regions. The high

prevalence of HIV/AIDS contributes to the high level of malnutrition among men,

women and children in Namibia. HIV/AIDS affects the most productive segment of the

population, which negatively affects household income as a result of increased health

expenditure and low productivity which in turn leads to food insecurity in the family

and society at large.

During a 2008 assessment of food and nutrition needs of people living with HIV/AIDS

(PLHIV) in Namibia conducted by the MoHSS and the Food and Nutrition Technical

Assistance (FANTA) project using BMI in 319 HIV-positive adults, 80 percent of whom

were on antiretroviral therapy (ART), it was shown that three per cent of PLHIV were

severely malnourished and 20 per cent were moderately malnourished. Almost all

clients rated access to healthy foods as their most serious concern after

unemployment, and almost all reported food insecurity.

1.12.3 Alcohol and nutrition

There are no national data on alcohol consumption and its effect on the health and

nutrition situation of the population. The Namibia household income and expenditure

survey of 2003/2004 report that Namibians spend an average of N$556 per annum on

alcoholic beverages and tobacco.19 This expenditure is much higher in males than in

females (N$729 vs. N$310) and in urban settings than in rural ones (N$821 vs. N$376,

19Central Bureau of Statistics, Republic of Namibia (2006). 2003/2004 Namibia Household Income and Expenditure Survey.

32


respectively). However, this last reported fact cannot be related to actual

consumption since most rural households produce local sorghum beer for their own

consumption.

The Report on the Namibia School-based Student Health Survey (2004) revealed that

the prevalence of alcohol use among students, i.e., drinking alcohol on one or more

days in the past 30 days, is 14 per cent and male students were more likely to drink

alcohol than their female counterparts.

The prevalence of alcohol abuse and the use of tobacco contribute to nutritional and

socio-economic problems in Namibia and increase susceptibility to diseases and

infections as well household income insecurity.

PART II: IN-DEPTH ASSESSMENT

2.1 METHODOLOGY

The Namibian national Nutrition Landscape Analysis (NLSA) was a descriptive study

carried out between October and November 2011. A total of 192 stakeholders and

service providers were interviewed in the assessment. The assessment was conducted

by a team drawn from different stakeholders including line ministries, UN agencies,

bilateral and multilateral organisations and NGOs, under the leadership of MoHSS.

33


Institutions included in the assessment team were members of the NAFIN platform.

The stakeholders who were interviewed were identified based on past or future

activities that they engage in relating to nutrition. Teams administering the

questionnaires worked in pairs or threes.

2.1.1 Preparation

The FHD of the Directorate of PHC Services of the MoHSS was the lead government

agency which, in collaboration with the WHO-Namibia office, led a multi-stakeholder

team endorsed by NAFIN in undertaking the NLSA. The team was approved and

appointed following endorsement by the Chair of NAFIN and the entire NAFIN body at

a meeting held on 26th September 2011. The chair of the Maternal Infant and Young

Child Nutrition (MIYCN) Technical Working Group was tasked with heading the team

for the NLSA, and reporting back to NAFIN. The organising team was headed by food

and nutrition staff from the MoHSS in order to provide necessary guidance in

undertaking the activity (see Annex 1 and Annex II).

The field team was engaged in the planning and preparation for the work related to

the NLSA from the outset of the process. The team reported back to the Chair of

MIYCN. The field tools were shared among the organisations and individuals that had

been identified as part of the field team for comments in preparation for adaptation

workshops. Two workshops (one of four days’ duration and one of two days) were held

in Windhoek in September and October 2011 to adapt the tools and to train the field

teams. External support from WHO Geneva was provided in the second adaptation

workshop held prior to the team leaving for the field.

The steps leading up to the ‘assessment in the field’ component are summarised

below:

1. Endorsement of the NLSA exercise by NAFIN;

2. Presentation of the study design and the study instruments to MIYCN;

3. Identification of field research team;

4. Sharing of the field study tools by WHO through MoHSS and submission of

appropriate revisions by stakeholders;

5. Identification of study design: national interviews and then interviews at 13 regions

and 15 districts nationwide (Table 4 below lists the regions of the country visited and

each district that was included into the NLSA).

6. Selection of study areas;

7. Tools adaptation workshops and training of field staff for data collection;

8. Attending to all field logistics required for implementation;

9. Sending correspondence to the regional governors’ offices, regional health

management teams, and district-level facilities informing them about the Namibia

NLSA survey

10. Setting dates for field visits;

11. Implementation of the field-based component;

34


12. Conducting interviews.

Table 4: List of regions and districts for in-depth assessment

Region Districts visited

Caprivi Katima Mulilo

Kavango Andara

Oshikoto Tsumeb

Ohangwena Engela

Omusati Outapi

Okahao

Oshana Oshakati

Kunene Khorixas

Erongo Walvis Bay

Otjozondjupa Otjiwarongo

Omahake Gobabis

Hardap Mariental

Rehoboth

Karas Keetmanshoop

Khomas Windhoek

2.2 PURPOSE OF THE NLSA

The NLSA was endorsed by NAFIN in September 2011. In November 2011, Namibia was

accepted as the 25th country to join the Scaling Up Nutrition (SUN) movement. In

February of 2012, the Prime Minister as the Chair of NAFIN was chosen to be part

of a high level group known as the Lead Group comprising heads of state, prime

ministers, ministers of finance and heads of international organisations. In joining the

SUN movement, Namibia is required to fulfil certain requirements, including

undertaking a situation assessment. In this context, the country has fulfilled one of

the SUN membership requirements by proactively undertaking the NLSA in Namibia.

The general objective of the NLSA was to assess the country’s readiness and capacity

to scale up effective nutrition interventions through multi-sectoral participation.

35


The specific objectives of the assessment were:

To assess the policy environment in relation to nutrition interventions in the country.

To engage key policymakers and senior managers to identify key constraints and analyse

the capacity gaps hindering the optimal scaling up of nutrition-related activities.

To make strategic, relevant and specific recommendations to the national plans of

actions in the scaling up of nutrition-related activities.

To come up with a country scale-up plan based on the readiness and capacity to scale

up nutrition interventions.

To develop a multi-sectoral conceptual framework to support effective coordination

among stakeholders in scaling up nutrition.

To build the capacity of stakeholders to conduct a detailed programmatic assessment

by participating in this process.

2.3 STUDY INSTRUMENTS

Seven study instruments were used in the assessment and six of these are attached in

Annex III.

Form 1: National-level stakeholders. Semi-structured interviews for

government agencies and other stakeholders (e.g., UN agencies,

donors, NGOs) at national level.

Form 2: Regional-level stakeholders. Semi-structured in terv iews for

government agencies and o ther s takeho lders at regional

level.

Form 3: District-level management staff. Semi-structured interview.

Form 4: Facility manager and staff responsible for nutrition (including facility

check list). Semi-structured group interview.

Form 5: Health workers. Structured questionnaire interview for all clinic staff

providing services to pregnant women or children.

Form 6: NGO field office. Structured interview with management and/or

nutrition programme officer of NGO providing services to women and

children.

Tool 7: Stakeholder mapping tool. Excel file to map resources committed to

nutrition, the location of nutrition activities, and target groups of the

activities and interventions.

36


2.4 DATA ANALYSIS

Data were collected onto the appropriate form and entered by the teams into a MS Excel

spreadsheet. The quantitative data were tallied to generate counts, totals and percentages of

responses.

The qualitative data were summarised using a data analysis guidance sheet provided

by WHO Geneva. The strengths and weaknesses of the qualitative data were outlined,

in addition to the findings reported. There were three phases of analysis done, the

first to collate the qualitative data, the second to synthesise the quantitative data

using the guidance sheet, and the third to collate the data at national and regional

levels for compiling the report. A separate analysis was carried out for each region in

the study.

The regional analysis was scored subjectively out of 100 in percentage, based on the

data analysis guidance sheet. The analysis team gave a score a percentage based on

the level of response of regions.

2.5 RESPONDENTS

In total, 192 respondents were interviewed for in-depth assessment in the field using

the NLSA survey tools. Interviews were undertaken at national level as well as at

regional and district levels.

A total of eight stakeholders at national level, comprising three from the state health

sector, three from non-health sectors and two from non-governmental

organisations were interviewed (see Table 5, below)

Table 5: Number of respondents at national level (in-depth assessment)

National level

Respondents

Government: health sector 3

Government: other sectors 3

UN agencies 0

Donors 0

NGOs (national level) 2

Total, national level 8

(UN and other development partners were interviewed during the desk review exercise.)

At regional level, 63 respondents were interviewed using the semi-structured

interviews. This included the regional governor or a designated representative;

councillors or members of the constituency development committee; chief medical

officers or members of the regional health management team; and officials in line

ministries, the respective ministry regional directors, or a designated representative.

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Table 6, below, summarises the number of respondents from different stakeholder

groups at regional level.

Table 6: Number of stakeholders interviewed at regional level

Respondents

Region Governor/

representative

Constituency development committee

Regional management

team

Line ministry regional

director or representative

Total

Caprivi 1 1 1 1 4

Kavango 1 1 1 2 5

Oshikoto 1 1 1 1 4

Ohangwena 1 1 1 2 5

Omusati 2 1 1 1 5

Oshana 1 0 2 2 5

Kunene 1 1 2 1 5

Erongo 1 1 1 2 5

Otjozondjupa 1 2 2 0 5

Omaheke 2 1 1 1 5

Hardap 1 1 1 2 5

Karas 0 1 2 5 8

Khomas 0 0 2 0 2

Total 63

At the district level, 17 respondents in total were included in the survey. Fifteen out

of the 34 MoHSS health districts were included in the assessment. One district per

region was selected but the team managed to visit Outapi District in Omusati Region

and also Mariental District in Hardap Region additionally. Only health personnel were

included in the district-level interviews, i.e., the principal medical officer (PMO)

who is a medical doctor who oversees all health services at the district level or the

primary health care supervisor, who is a registered nurse responsible for all aspects of

primary health care and special programmes (HIV/AIDS, TB, malaria and STIs) at

district level.

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Table 7: Number of respondents at district level

Region District Total

respondents

Caprivi Katima Mulilo 1

Kavango Andara 2

Oshikoto Tsumeb 1

Ohangwena Engela 1

Omusati Outapi, Okahao 2

Oshana Oshakati 1

Kunene Khorixas 2

Erongo Walvis Bay 1

Otjozondjupa Otjiwarongo 2

Omaheke Gobabis 0

Hardap Mariental, Rehoboth 2

Karas Karasburg 1

Khomas Windhoek 1

Total 17

Thirty-one facility managers were interviewed; this process included the

administration of a health facility checklist whereby the availability of equipment

and supplies, as well as the implementation of health and nutrition interventions,

was assessed. At the district hospital, the hospital matron and the registered nurse

in charge of the clinic were interviewed.

Table 8: Number of facility managers interviewed at facility level

Region Total

respondents

Caprivi 3

Kavango 4

Oshikoto 1

Ohangwena 1

Omusati 4

Oshana 3

Kunene 1

Erongo 2

Otjozondjupa 4

Omaheke 2

Hardap 2

Karas 2

Khomas 2

Total 31

39


The knowledge and confidence of health workers were assessed at the clinic,

health centre or district hospital. The health workers targeted were staff providing

services to pregnant women and children. Fifty nine (59) health workers were

interviewed.

Table 9: Number of health workers interviewed at facility level

Region Total

respondents

Caprivi 2

Kavango 2

Oshikoto 2

Ohangwena 2

Omusati 2

Oshana 2

Kunene 2

Erongo 2

Otjozondjupa 2

Omaheke 2

Hardap 2

Karas 2

Khomas 2

Total 59

A total number of 14 interviews at NGOs were conducted in various regions during

the assessment. The questionnaire was administered to the management or

nutrition programme officer of the NGO providing health and/or nutrition services

to women and children.

40


Table 10: Respondents by NGO

Region NGO Position of respondent

Caprivi Project Hope Regional Manager

Caprivi Namibia Red Cross Society (NCRS) Regional Manager; Food Security Officer

Erongo Evangelical Lutheran Church in Namibia (ELCIN) Pastor

Hardap Community Health Care Services Namibia (COHENA) District Field Supervisor

Hardap Catholic AIDS Action (CAA) Regional Coordinator / Palliative Care Nurse

Karas CAA Regional Manager

Kavango Societies for Family Health (SFH) Administrative Assistant/MCH Officer

Kunene NCRS Software Officer

Omaheke CAA Regional Coordinator

Omaheke COHENA Regional Programme Coordinator

Omusati NCRS Volunteer

Oshana CAA Regional Manager

Oshana ELCIN Coordinator Western Diocese

Otjozondjupa Orange Babies Centre Manager

2.6 RESULTS

Findings of the study are presented under two broad headings: ‘Commitment to act’

and ‘Capacity to act’, representing the willingness and ability, i.e., readiness, of

stakeholders and service providers in the country to accelerate action in nutrition.

2.6.1 Awareness of nutrition problems and underlying

causes, as perceived by stakeholders

As a prerequisite for stakeholders to be committed to accelerate the reduction of

maternal and child under-nutrition, they need to be aware of the existing nutrition

problems and their causes.

Out of the 63 regional respondents who were asked what the major nutrition

problems in Namibia are, 33 (52 per cent) mentioned under-nutrition, 28 (44 per

cent) mentioned underweight, and 17 (27 per cent) mentioned wasting as the three

most common nutrition problems. Stunting, and vitamin and mineral deficiencies,

were also mentioned but were not perceived as major problems by the majority of the

respondents. Specific vitamin deficiencies such as vitamin A deficiency were not

mentioned as a problem.

41


Figure 4: Regional and national figures: perceived major nutrition problems

When asked what the major contributing factors to nutrition problems are, 32

respondents (50.7 per cent) of the total 63 respondents reported food insecurity.

Unemployment stood second, with 26 (41.2 per cent) of the respondents mentioning

unemployment as an underlying cause for the high malnutrition level in Namibia.

42


Figure 5: Regional and national figures: perceived causes of nutrition problems

2.6.2 Documents used for nutrition advocacy

All the regions mentioned using the Vision 2030, MDGs and NDP documents as the most

common tools for nutrition advocacy. Other documents used for advocacy include:

IYCF guidelines, those relating to women’s rights, and the Namibia nutrition profile.

Figure 6: Documents used for nutrition advocacy

2.6.3 Commitment of stakeholders to scale up nutrition

action

The various stakeholders mentioned a series of specific contributions that they could

make to support the scaling up of nutrition action. The contributions identified by different

stakeholders include several activities with some degree of overlap. The actions suggested

by the MoHSS range from policy development to capacity building; conducting research and

developing interventions for the Integrated Management of Acute Malnutrition (IMAM)

approach; improving general awareness; changing food-related behaviour; better inter-

sectoral coordination; and supporting evidence-based nutrition interventions. Other

stakeholders mentioned that they could contribute to scaling up nutrition action through

strengthening health education; conducting social mobilisation; improving inter-sectoral

coordination at national and regional level; and implementing monitoring and evaluation.

43


However, national- and regional-level staff also identified a series of barriers to

scaling up nutrition action, including inadequate financial and human resources;

nutrition not being considered a priority; and inadequate training. Accordingly, the

top priority needs at both national and regional level were identified to be: human

resources for scaling up nutrition action; financial resources; and capacity

development.

The main barriers to scaling up nutrition as perceived by different stakeholders are

limited financial resources available for nutrition activities arising out of a lack of

budget lines, or resources not allocated at all to nutrition. The other chief barrier to

scaling up nutrition interventions is lack of adequate human resources, as there are no

full-time nutrition staff members in the regions, and only one nutritionist serving at

national level (with an additional four staff supported by donors). Furthermore, there

is no tertiary pre-service training for nutrition and among in-service staff there is a

high staff turnover, little or no incentive for well-trained personnel to stay in service,

and a lack of inter-sectoral coordination. These were also mentioned among the

barriers for scaling up nutrition interventions.

2.6.4 How would nutrition be scaled up with existing

resources?

With existing resources, stakeholders proposed scaling up of training in nutrition;

deploying community-based health workers to support nutrition; advocacy; and

creation of awareness on nutrition. Additionally, collaboration with different

stakeholders was identified as a way to scale up nutrition by pooling human and

financial resources. Finally, the need for fundraising to increase the resources

available for nutrition was cited as another measure to facilitate the scale up of

nutrition.

Almost all the NGOs interviewed responded to this question by indicating that they

would scale up community interventions such as community education, community

mobilisation, and training of communities on malnutrition. Moreover, behaviour

change communication; working towards the changing knowledge attitudes and

practices in communities about nutrition and food security; as well as gardening,

poultry and provision of seed, were mentioned as initiatives that can be scaled up

using existing resources.

NGOs involved in the education sector mentioned that the provision of school uniforms

and supporting students until they reach secondary school could be used as potential

vehicles to scale up nutrition. The scaling up of the provision of formula milk was

suggested as an activity using existing resources. This request calls for orientation of

NGOs operating in the country with the policy of the government, which promotes

exclusive breastfeeding up to six months of age and weaning food thereafter (while

continuing breastfeeding for two years or more).

Caprivi:

44


The Caprivi Region indicated that distance, staff shortages, lack of transport,

inadequate budget, lack of commitment by all ministries, and the lack of

infrastructure and nutrition experts were all barriers for scaling up nutrition in the

region.

The region is, however, liaising with councillors to visit all communities and health

centres to better understand its nutrition challenges. It is also providing opportunities

to train its staff, sharing information and resources for nutrition, and involving other

stakeholders in taking part in nutrition interventions.

Awareness and adherence to nutrition protocols from the health workers: in the

Caprivi Region, no health worker was aware of the 2010 Nutrition Assessment, Counselling

and Support For PLHIV, Operational Guidelines (shortened to ‘NACS programme protocols’

here), WHO 2003 Guidelines for the clinical inpatient treatment of severely malnourished

children, or any other nutrition programme protocols.

Erongo:

Erongo Region mentioned its large population, inadequate budget, need for high-level

commitment for nutrition, staff shortages, lack of information, cultural influences,

unemployment, poverty and ignorance to be barriers for scaling up nutrition.

To address the barriers indicated above, the region is drafting proposals for funding by

donors in the region. The region is also advocating for poverty reduction, job creation

and information sharing.

With the available resources, the region wants to persuade high-level leaders of the

need for regular supervision at lower levels, and training of staff members on health

and nutrition in order to scale up nutrition interventions.

Awareness and adherence to nutrition protocols from the health workers: in

Erongo Region, no health worker was aware of the NACS, WHO 2003 Guidelines for the

inpatient treatment of severely malnourished children, or any other nutrition

programme protocols.

Hardap:

Hardap Region indicated staff shortages, lack of budget, lack of knowledge and skills

of health workers in nutrition, the MoHSS working in isolation (no inter-sectoral

collaboration), unawareness of nutrition at the community level, unsustainable donor

projects, lack of involvement of higher authorities, and lack of land to be the barriers

for scaling up nutrition.

To address the above barriers, the regional is working towards: strengthening

coordination for nutrition; involving communities in nutrition programmes;

approaching the regional governor to convene meetings; modifying the school

curriculum to cover nutrition issues; creating community education campaigns

targeting young mothers; sensitising line ministries and leaders on nutrition; and

involving the town council to provide land.

45


With the resources they have, they want to strengthen coordination; come up with

action plans and TORs; create awareness campaigns in the community; educate hostel

officers about nutrition; put nutrition in the agenda of CDC meetings; and implement

the training of health workers.


Hardap Region, health workers were aware of the NACS and the WHO 2003 Guidelines

for the inpatient treatment of severely malnourished children programme protocols.

Direct funding available to community-based organisations for nutrition activities:

in Hardap Region, those interviewed did not know that direct funding was available to

community-based organisations for nutrition activities.

Karas:

Karas Region indicated no post for a nutritionist, staff shortages, lack of knowledge

and skills of health workers, lack of community awareness about nutrition, inadequate

funding, alcohol abuse, no supplementary programmes in schools, and the priorities of

agencies not being aligned with regional priorities to be the barriers for scaling up

nutrition.

To address the above barriers, the region is training staff; conducting awareness

campaigns; submitting budget requirements; and encouraging the involvement of

community leaders. The region wants to scale up in order to educate communities;

train the youth; train staff to train others; strengthen outreach programmes; provide

treatment for malnourished children; and strengthen monitoring and evaluation.

Awareness and adherence to nutrition protocols from the health workers: in Karas

Region, health workers were aware of the NACS and GMP programme protocols.

Kavango:

The barriers for scaling up nutrition in Kavango Region are: shortage of transportation

facilities, lack of awareness and cooperation from the communities, and little

sensitisation on nutrition compared to HIV/AIDS and TB.

Kavango is encouraging the community to work hard to produce food as part of the

initiative to ensure food security in the region. The region indicated that its land is

fertile and people need to work hard to improve their nutritional status. With the

resources available, Kavango Region would like to disseminate and orientate on the

existing policies and guidelines; motivate for increasing staff establishment; and

strengthen coordination.


Kavango Region, health workers were aware of the NACS, WHO 2003 Guidelines for

the inpatient treatment of severely malnourished children, and the Nutrition and HIV


Khomas:

The barriers for scaling up nutrition in Khomas Region are inadequate funding and

staff shortages, and the fact that staff are unable to go to the communities to scale

up nutrition. The region is drafting proposals to solicit funding; had appointed a media

46


liaison officer to work with the communities; and assigned nurses to work with the

community health promoters.

With the available resources the region wants to scale up training of staff; strengthen

monitoring and supervision; and focus on informal settlements, e.g., teach community

members proper feeding practices to reduce malnutrition.


Khomas Region, health workers were aware of the NACS programme protocols.

Kunene:

The barriers for scaling up in Kunene are: lack of insight that nutrition is a subject on

its own, lack of understanding of the different values of food, lack of coordination,

lack of knowledge of health workers, and lack of staff and funding. The region is

undertaking community sensitisation meetings; dissemination of information to the

youth; motivating for increase in staff establishment; using the constituency

development committee as a platform to get messages across; and putting nutrition in

the agenda of the regional meetings.

With resources available, Kunene would like to scale up sensitisation of stakeholders

involved in nutrition; enhance capacity development; and recruit more staff for

nutrition.


Kunene Region, health workers were aware of the WHO 2003 Guidelines for the

inpatient treatment of severely malnourished children programme protocols.

Ohangwena:

Barriers for scaling up on nutrition interventions in Ohangwena were poverty (people

not able to buy food), ignorance, poor coordination, over-dependence on relief aid,

apathy of the community in taking the initiative for improving nutrition interventions,

no focal person for the nutrition programme, and inadequate equipment.

To address the barriers, Ohangwena Region would advocate for poverty reduction;

improve coordination; educate communities; encourage people to be productive; and

write proposals to solicit funds.

With the resources available, Ohangwena like to scale up home gardening; food

diversification at community level; coordination of NGOs; promotion of the use of

local foods; education on food preparation and storage; promotion of the avoidance of

the use of alcohol; and advocacy for nutrition in constituencies.


Ohangwena Region, three out of four health workers were aware of the NACS


Budget availability for nutrition: in Ohangwena Region, the Ministry of Agriculture,

Water and Fisheries had budget lines specifically for nutrition in the area of food

security.

47


Omaheke:

The barriers for scaling up nutrition in Omaheke Region are: lack of human and

financial resources, disintegration of the social services, and the movement of social

workers to other line ministries, lack of information and proper training, delays in

decentralisation, and inadequate budget for vulnerable populations.

The region is involving other partners (such as the regional emergency management

unit); advocating for social workers to be under one ministry; advocating for

lawmakers to recognize nutrition as a key problem; and speeding-up decentralisation

in order to address the barriers mentioned above.

With the available resources Omaheke would like to scale up training and capacity

building of health workers.


Omaheke Region, no health worker was aware of the NACS, WHO 2003 Guidelines for

the inpatient treatment of severely malnourished children, or any other nutrition


Integration of nutrition actions into other health and non-health policies (HIV,

IMNCI, MCH): regional stakeholders interviewed in Omaheke Region could not provide

information on any specific nutrition interventions.

Omusati:

The barriers for scaling up of nutrition interventions in Omusati Region are poverty

and ignorance, lack of human and financial resources, and a lack of coordination

between national priorities and the needs of the population in the ground. Omusati is

trying to address the issues through the inclusion of a nutrition plan; allocation of

resources; involvement of stakeholders; and approaching donors for funding.

With the limited resources they have, Omusati would like to scale up community awareness

on nutrition; enhance enrolment of children in the Integrated Management of Acute

Malnutrition approach; and train community members on feeding children properly.

Awareness and adherence to nutrition protocols from the health workers: in Omusati

Region, health workers were aware of the NACS, WHO 2003 Guidelines for the inpatient

treatment of severely malnourished children, and the IMNCI programme protocols.

Oshana: The barriers for scaling up nutrition interventions in Oshana are distance, staff with too

much responsibility, lack of ownership and commitment, lack of volunteerism and

volunteers not getting enough incentives, lack of understanding about nutrition, and lack of

human and financial resources. The region is advocating for high-level political commitment

and is supporting students to implement what they have learned in university.

With available resources, Oshana would like to: involve churches in influencing people;

encourage and train people to participate in nutrition interventions; sensitize and mobilise

mothers to breastfeed; and intensify partnerships with the MoHSS.

48


Awareness and adherence to nutrition protocols from the health workers: in Oshana

region, all three health workers were aware of the NACS programme protocols.

Integration of nutrition actions into other health and non-health policies (HIV,

IMNCI, MCH): some regional stakeholders interviewed in Oshana Region could not

provide information on any specific nutrition interventions.

Appropriate number of skilled staff at each level of service delivery for scope of work

provided: Oshana Region had a large number of community-based workers on the ground

who were not captured by this indicator as they are unskilled workers.


in Oshana Region, those interviewed did not know that direct funding was available to

community based-organisations for nutrition activities.

Oshikoto:

The bottlenecks for scaling up nutrition interventions in Oshikoto Region are: lack of

community awareness to take up nutrition interventions at community level, lack of

technical working groups (TWGs) coordinating nutrition interventions, and lack of

transport/poor roads deep in the villages. The region is involving the communities;

encouraging the regional management team to form a TWG; creating linkages with

other ministries; engaging other stakeholders to provide transport; and liaising with

other government agencies to improve roads.

Oshikoto would like to scale up: capacity building of communities; advocacy; the

inclusion of nutrition in work plans; promotion of provision of lands for cultivation;

and re-strategising food relief.


Oshikoto Region, both health workers were aware of the NACS programme protocols.

Otjozondjupa:

The barriers for scaling up nutrition interventions in Otjozondjupa Region are: a lack

of funding/financial resources and a focal point for nutrition, and a lack of

information and awareness among the community and regional staff about nutrition.

The region is lobbying for funds; seeking information from MoHSS; making water and

land available to the people to produce food; and increasing awareness of the

population on nutrition, in order to address the barriers mentioned above.

With the limited resources, the region would like to scale up: streamlining of nutrition

into development programmes; creating multi-sectoral collaboration; advocating with

regional councillors; encouraging community gardening and chicken farming; and

developing sensitisation and community awareness campaigns on nutrition.


Otjozondjupa Region, health workers were aware of the NACS programme protocols.

Budget availability for nutrition: most Otjozondjupa Region stakeholders, both in the

health and non-health sectors, had no budget lines specifically for nutrition. In the

49


regional MoHSS there was a budget available for nutrition that is integrated into the

Primary Health Care budget but it was not possible to obtain disaggregated data.


in Otjozondjupa Region, those interviewed did not know the direct funding that was

available to community-based organisations for nutrition activities.

2.7 RESOURCE ALLOCATION FOR NUTRITION

All stakeholders at national level (both in the health and non-health sectors) and

those at the regional level said that the main source of funding for nutrition

programmes currently is donor organisations. Almost all stakeholders at national and

regional level said that the funds for nutrition programmes are not adequate.

At all government administrative levels, a majority of stakeholders identified lack of

financial and human resources as a major barrier to implementing nutrition actions.

Other important factors identified were: poor inter-sectoral coordination, poor

infrastructure, and nutrition not being considered a priority. Poverty as a key

underlying determinant was also considered as a barrier. Most regional- and district-

level managers reported that they do not have a budget for nutrition activities.

2.8 INTEGRATION: INCORPORATION OF NUTRITION INTO

PLANS AND PROGRAMMES

Many sectors have an impact on nutrition. Education plays an important role in

improving the health of young children and adolescents. Agriculture is important for

food security through programmes such as the provision of fertilizer subsidies,

promotion of agricultural production, improved technology to minimise post-harvest

losses, and promotion of home gardening. Social welfare grant programmes increase

household income and can result in better access to food or health care. Indeed in

Namibia, a number of sectors contribute to improved nutrition through nutrition-

sensitive policies and actions.

50


Table 11: Integration into other sectoral programmes

Line ministry or sector Nutrition-sensitive actions

Ministry of Defence

Ensures a safe and secure environment for the production of food

Provides logistical and human resource support for food delivery in emergencies, including the drought relief delivery programme

Educational awareness campaigns on HIV, TB, and other related communicable diseases that may lead to nutrition deficiency

Logistics support for nutrition- and health-related activities such as NIDs, Child Health Days and emergency response

Ministry of Labour and Social Welfare

Provides social and disability grants

Ensures adherence to the labour law regarding maternity leave and the protection of breastfeeding (maternity leave)

National Planning Commission

Facilitation role to bring together the different line ministries to align resources for nutrition action

Monitoring of programmes and resources allocated for nutrition programmes

Ministry of Information, Communication and Technology

Awareness raising on nutrition issues disseminate information through print and electronic media and health literacy

Ministry of Regional and Local Government, Housing and Rural Development

Through RDCCs, CDCs and village/community development committees, coordinate community-based nutrition and income-generating activities in partnership with CSOs

Rural infrastructure

Social mobilisation

Increase demand for nutrition services

Coordinate nutrition response (food aid)

Access to health care and food markets

Ministry of Gender Equity and Child Welfare

Child grants

Food security at household level

Ministry of Education

School feeding programmes

School health programmes

Include nutrition as part of the curriculum

Sanitation

Nutrition education and information

Ministry of Agriculture, Water and Forestry

Green scheme

National Horticulture Development

Food security: food production, e.g., dry land crop production

Strategic food reserve facilities (silos)

Water and sanitation – health and hygiene

51


2.9 COORDINATION FOR NUTRITION

2.9.1 National coordination mechanisms

MoHSS:

The MoHSS has different platforms for coordination of health and nutrition

interventions in the country. These are the National Maternal Child Health and

Nutrition Management Committee, the Maternal and Peri-Neonatal Death Review

Committee, and the Maternal, Infant and Young Child Nutrition (MYCIN) Technical

Working Group, which is part of the sub-groups of NAFIN. The advantages of having

these coordination mechanisms as described by different stakeholders were that these

coordination platforms maximise the use of the limited resources and strengthen

information sharing. Challenges cited were the limited participation by tertiary

institutions and the broader spectrum of line ministries and government agencies.

Ministry of Gender Equality and Child Welfare:

The Ministry of Gender Equality and Child Welfare coordinates the Orphan and

Vulnerable Children (OVC) forum. The platform meets quarterly. Cited as a strength of

this coordination platform was the multi-sectoral and multi-stakeholder nature of the

forum; however despite having this forum, the implementation of policies and

strategies is slow and is described as a weakness.

NGOs:

The NGOs Development Aid from People to People in Namibia (DAPP) and Catholic

AIDS Action (CAA) do not have a coordination mechanism for nutrition at national

level. However DAPP is a member of the regional AIDS coordinating committees

(RACCOCs) as well as the constituency AIDS coordinating committees (CACCOCc).

2.9.2 Regional coordination mechanisms

There are also regional coordination mechanisms, e.g., regional development

coordinating committees (RDCCs) and regional AIDS coordinating committees

(RACCOCS), chaired by the chairperson of the regional council. However, it was

observed that these meetings do not take place quarterly as stipulated by the office

of the regional governor. These fora can be used as an opportunity to address food

and nutrition problems in the respective regions.

2.9.3 Involvement of government sectors and partners in

nutrition coordination

Monitoring of nutrition activities is undertaken by the Food and Nutrition Subdivision

of the Directorate of PHC Services of the MoHSS. Integration of nutrition into maternal

and child health programmes and protocols is not consistently done. The draft ‘Sexual

Reproductive, Child Health and Nutrition Policy’ includes nutrition policy statements.

The IMNCI programme includes nutrition in a satisfactory manner in that the Training

Manual for management of sick children under five years, at primary care level,

includes a substantial component on nutrition.

52


HIV programmes are within the purview of the DSP at the national level, with

activities implemented through the regional- and district-level health staff. Training

of health workers in relation to breastfeeding by HIV-positive mothers has been

undertaken by the PMTCT clinics.

2.9.4 Support to regions and facilities

Support is being provided by national, regional and district levels to the various health

facilities and administrative offices, e.g., RMT and DCC. Some support visits are done

annually (e.g., national), some bi-annually (e.g., at regional level) and some quarterly

(e.g., district level). Table 12, below, shows the respondents’ answers regarding the

question of support.

A total of 59 health workers were asked if they are adequately supported to carry out

nutrition activities and duties; 40 health workers (67.8 per cent) reported that there

is no adequate support while 19 (32.2 per cent) said they were adequately supported.

The majority of health workers reported they did not receive adequate technical

support and guidance on nutrition-specific issues and that they did not receive

adequate supervision from senior staff or national-level staff.

Table 12: Disaggregated responses of health workers regarding adequate support

The majority of health worker respondents in most regions reported having

inadequate support to carry out nutrition activities such as nutrition services and

counselling. The majority of respondents in most regions also reported having

inadequate time to carry out nutrition duties. All 13 regions stated that they did not

have adequate numbers of skilled human resources to perform nutrition duties. The

current health system structure does not include regional- or district-level dedicated

nutrition personnel or focal points.

Region Region

Capri

vi

Ero

ngo

Hard

ap

Kara

s

Kavango

Khom

as

Kunene

Ohangw

ena

Om

aheke

Om

usa

ti

Osh

ana

Osh

ikoto

Otj

ozondju

pa

Sta

ff m

oti

vati

on a

t all levels

Health workers are adequately supported to implement nutrition services and counselling

50 % 0 % 29 % 33 % 50 % 17 % 25 % 50 % 50 % 0 % 33 % 0 % 50 %

Health workers have adequate time to carry out nutrition duties

50 % 100 % 29 % 0 % 40 % 25 % 75 % 0 % 33 % 14 % 33 % 67 % 0

Nutritionist or staff with nutrition training to perform nutrition duties

0 0 0 0 0 0 0 0 0 0 0 0 0

53


2.10 HUMAN RESOURCES FOR NUTRITION

2.10.1 Capacity to act

Ability to scale up nutrition in Namibia remains critically constrained as human

resources remain severely limited. Up until 2010, there was only one trained nutrition

professional working for the Namibian government. Since then, three registered

nurses who had received in-service training on aspects of MIYCN, HIV and nutrition,

micronutrients, food safety, and nutrition surveillance, have joined the ranks at the

MoHSS.

In 2011, the Global Fund hired one nutritionist and two assistant nutritionists. The

nutritionist is based at the Food and Nutrition Subdivision and is coordinating the

Nutrition Assessment and Counselling Support (NACS) programme. Each of the two

assistant nutritionists is based at a regional health training centre (in the Kavango and

Karas regions) and assists with the implementation of the NACS programme. All of the

above also assist with capacity building for other staff members, both regionally and

at district level. The human resource constraints continue to limit not only capacity to

undertake and deliver existing programmes but also threaten scale up plans for

nutrition.

Currently, there is no standalone nutrition course at the tertiary institutions in

Namibia. Nutrition is integrated as a component of the nursing degree and the Masters

in Public Health at the University of Namibia in the School of Nursing and Public

Health. In addition, nutrition is taught as a unit within the Masters in Public Health

Education course, towards qualifications in teaching home economics and science-

based subjects.

Capacity to act is also limited due to constraints in financial and human resources in

implementing nutrition activities at regional and district levels. This was reflected in

the governors’ ‘Declaration of Commitment’ given in August 2011.

54


2.10.2 Human resources and quality of services

Figure 7: Distribution of staff with appropriate skills at all levels

National level: Directorate of

Primary Health Care Services.

Food and Nutrition Subdivision

1 Programme Manager

3 Programme officers

Nutritionist (supported by

Global Fund)

District level: district-level

health clinics

Medical officers and

nurses

Regional level (13 regions)

2 assistant nutritionists

supported by the Global

Fund, attached to 2

regional training centres

Medical officers and

nurses

34 hospitals

Medical officers, nurses

and dieticians working in

two intermediate

hospitals.

Training in nutrition

The Programme Manager and the Global

Fund-supported staff are the only

qualified, trained nutritionists working

within the Ministry of Health and Social

Services.

Programme officers are not trained in

nutrition


No healthcare providers at regional and

district levels are trained as qualified

nutritionists.

In-service training in some areas such as

in-patient management of acute

malnutrition; nutrition and HIV; IYCF

counselling; GMP and NACS is conducted.


No healthcare providers at district level

with nutrition qualifications.

In-service training in some areas such as

nutrition and HIV, IYCF counselling, GMP

and NACS is conducted.

Min

istr

y o

f H

ealt

h a

nd S

ocia

l Serv

ices

Community level

Active community-based health care

providers (CBHCPs) at some districts

implementing nutrition counselling,

MUAC, and raising nutrition awareness

Pilot phase to implement health

extension workers in one district is

underway.


Some CBHCPs in some district have under

gone orientation and training on MUAC,

GMP, and general nutrition counselling.

55


In Namibia the health workforce members at all levels are the key providers of

nutrition-related services. These services are mostly integrated with other health

programmes such as maternal and child health, HIV, and PMTCT. Please note:

Omaheke Region district managers were not present during the interview in question

and are therefore not represented in the relevant figures that follow.

Figure 8: Number of regions implementing recommended community-based MCH activities

Figure 8, above, illustrates the eleven MCH interventions identified as active by

district-level managers in the regions. The responses are categorised by regions

reporting. The interventions were both nutrition-specific and nutrition-sensitive

interventions.

Of the nutrition-specific interventions, only the identification and referral of

moderately and severely malnourished children was undertaken by all the regions, as

well as nutrition education for pregnant women. The promotion of iodised salt was

undertaken by five of the 13 regions; the regions that were involved in the promotion

activities were Caprivi, Kavango, Omusati, Oshikoto and Otjozondjupa. Kavango and

Otjozondjupa reported not undertaking nutrition assessment of pregnant, postpartum,

and lactating women, since the NACS programme was not yet implemented in their

regions. Adolescent Friendly Health Services activities were undertaken in Caprivi,

Kavango, Oshikoto, and Otjozondjupa probably in response to these being the

regions with the highest teenage pregnancy rates.

In Caprivi, Karas, Ohangwena and Oshana regions, the nutrition-sensitive activities of

home and community gardening were reported as not being undertaken. Promotion of

deworming, which is a nutrition-sensitive activity, was not undertaken in Hardap,

56


Khomas and Kunene regions. Family planning activities were not reported in Kunene

region. All regions were engaged in diarrhoea prevention activities. In the promotion

and provision of insecticide treated bed nets, Erongo, Hardap, Karas, Khomas and

Kunene regions reported that there were no activities ongoing, since they are non-

epidemic regions so far as malaria is concerned. Caprivi, Oshikoto and Otjozondjupa

reported that they were not engaged in the distribution of oral rehydration solution

for diarrhoea management.

The nutrition-specific interventions surveyed in this section were the promotion of

iodised salt; the identification and referral of moderately and severely malnourished

children; nutrition assessment of pregnant, postpartum, and lactating women; and

nutrition education of pregnant women. Nutrition-sensitive interventions surveyed in

this section were: promotion of deworming; home and community gardening; family

planning and Adolescent Friendly Health Services; prevention of diarrhoea; provision

of oral rehydration solution; and the promotion and provision of insecticide-treated

bed nets.

Figure 9: Number of regions implementing recommended community-based education-related nutrition activities, as informed by district-level managers

The number of regions implementing recommended community-based education-

related nutrition activities varied. All 12 regions claimed that they implement school

health programmes in their respective regions. However, only six regions, namely

Hardap, Omusati, Ohangwena, Kunene, Khomas and Otjozondjupa mentioned that

they implement a school feeding programme in their respective regions. The least-

mentioned activity was Early Childhood Development (ECD), only four regions (Erongo,

Kavango, Omusati and Otjozondjupa) are implementing this strategy.

57


Figure 10: Number of regions implementing recommended community-based food security/livelihoods/income-generating activities

Eight regions have reported that they are implementing vegetable gardening and soup

kitchen projects (primarily supported by churches). Six regions are promoting small-

scale farming and four regions are promoting food diversification and also providing

food relief. Three regions reported that they have a food-for-work programme and

two regions are implementing aquaculture. Only one region promotes use of animal

food sources, e.g., meat, fish, etc.

Figure 11: Number of regions implementing recommended community-based water and sanitation activities

58


Figure 11, above, illustrates the number of regions identified through interviews with

district level managers to be undertaking essential water, sanitation and hygiene

(WASH) activities. All district level managers interviewed in the regions reported that

their region was engaged in the promotion of hand-washing and the promotion of safe

drinking water. Only one region (Oshana) did not report activities in waste disposal.

There were no reports on the distribution of water purification tablets in Erongo,

Hardap, Khomas, Kunene and Otjozondjupa regions.

Figure 12: Number of regions implementing recommended community-based IYCF activities and prevention of mother-to-child transmission (PMTCT) as informed by district-level managers

Out of the total 12 regions that were asked what recommended community-based

IYCF activities they are implementing, all 12 regions mentioned that they promote

breastfeeding, including exclusive breastfeeding up to six months as recommended in

IYCF.

In addition, 11 out of the 12 regions interviewed mentioned complementary feeding

promotion as an intervention, with the exception of Kunene Region. However only

nine regions mentioned PMTCT as an intervention used in community-based IYCF.

59


2.11 HUMAN RESOURCES WITH NUTRITION TRAINING

Figure 13, below, indicates any form of nutrition training (including degree

programme) on nutrition. As can be seen, only one member of staff has advanced

training in nutrition. A total of 23 members of staff were reported to be trained in

nutrition at the regional level and 41 at district level. There were 87 community

promoters who were trained in some form of nutrition at the community level.

Figure 13: Staff with nutrition training

As can be seen in Figure 14, below, only four staff members are working in nutrition

at the MoHSS national level. There are a total of 25 staff members working full-time

and 14 working part-time as nutrition staff at regional level, and 61 and 32

respectively at the district level. Eighty-seven community-based nutrition staff work

part-time in nutrition at the community level. It should be noted that the numbers

indicated are those who are working in any form of nutrition across all sectors.

The MoHSS does not have full-time staff for nutrition at all levels in the health care

delivery system, except at national level and two intermediate hospitals.

1 0 0 04

23

41

87

0

10

20

30

40

50

60

70

80

90

100

National Regional District Community

Staff with nutrition training

Number of staff withtraining Degree in

nutrition

Number of staff withtraining Other training

60


4

39

9387

4

25

61

00

14

32

87

0102030405060708090

100

Number of staff working in nutrition

Total

Number of staff working in nutrition Full-time

Number of staff working in nutrition Part-time

Figure 14: Numbers of staff working in nutrition

2.11.1 In-service training

A total of 59 health workers were asked what type of nutrition training they had received.

The range of nutrition topics covered by in-service training in the past 12 months is

depicted below.

Table 13: Number of health workers trained in various areas of nutrition (indicated on Form 5)

In-Service training programme Total (n= 59)

Maternal Nutrition 6 (10.2 %)

IYCN 16 (27.1 %)

Breastfeeding 16 (27.1 %)

Complementary Feeding 12 (20.3 %)

Counselling Skills 31 (52.5 %)

Micronutrients 14 (23.7 %)

Nutritional Care of Sick Children 15 (25.4 %)

Management of SAM/MAM 24 (40.7 %)

Nutrition and HIV 21 (35.6%)

Growth Monitoring and Promotion 18 (30.5 %)

Healthy Diets (including use of locally-available food and physical activity) 22 (37.3 %)

Hygiene and Food Safety 23 (39.0 %)

Other:

IMNCI

PMTCT

Early Infant Diagnosis

Voluntary Counselling and Testing

1 (1.7 %)

1 (1.7 %)

1 (1.7 %)

1 (1.7 %)

61


The limitation with in-service training is capacity to supervise and monitor health

workers after they have been trained. Transfer of new knowledge and skills into

practice is limited due to the low capacity of senior health administrators and

managers to actively monitor, supervise and mentor health workers.

2.11.2 Health worker knowledge

Table 14, below, indicates the percentage of correct answers as per the national

guidelines. The highest knowledge among health workers was on: how soon after

delivery a baby should be put on breastfeeding; on admission criteria for malnourished

infants less than six months of age; and concerning education to reduce obesity,

where the scores were 94 per cent, 96 per cent and 88 per cent respectively. The

other knowledge questions scored as low as four per cent.

Table 14: Knowledge test on various nutrition interventions among health workers

Knowledge test on various nutrition interventions among health workers

Percentage correct

responses (n = 50)

What micronutrient supplement should pregnant women receive? 11 (22%)

How soon after delivery should a baby be put to the breast? 47 (94%)

When should breast-fed children start receiving complementary foods? 34 (68%)

Should all infants receive vitamin A supplements? 14 (28%)

Zinc supplements should be given to all children who have diarrhoea? 17 (34%)

All children in all countries have the same potential to grow from birth until five years, which is reflected in the WHO Growth Standards?

36 (72%)

Children with severe acute malnutrition with complications, or younger than six months, should be admitted for in-patient treatment?

48 (96%)

Exclusively breastfed infants who get diarrhoea may need some water to replace loss of fluids?

22 (44%)

HIV-infected women who choose to breastfeed should practice exclusive breastfeeding up to six months and continued breastfeeding until 12 months?

34 (68%)

Overweight and obesity are the problems of the high income segment of society so education on balanced diets and healthy lifestyle is not necessary in poor communities?

44 (88%)

How soon after delivery should a baby’s umbilical cord be clamped? 19 (38%)

Which protocol do you use for the management of severe acute malnutrition of children?

2 (4%)

62


Figure 15: Interventions implemented at facility level to address child health

2.11.3 Counselling skills: quality of counselling given by

health workers

Table 15: Nutrition topics discussed during counselling

Nutrition topic discussed during counselling a mother/caregiver of a child who is not growing adequately

Percentage of respondents’ that covered this topic with

mother/caregiver of a child not growing adequately

Involves the mother in identifying the problem 35 %

Counsels on exclusive breastfeeding up to six months 22 %

Counsels on continued, frequent feeding on demand 43 %

Good hygiene and proper food handling practices 28 %

Variety of food 69 %

Amount and frequency of feeding 61 %

Fortified complementary food 24 %

Gives practical and feasible advice about infant and child feeding 30 %

Sets goal(s) with the mother/caregiver 13 %

Checks with the mother/caregiver that information given has been understood

11 %

63


Table 15, above, indicates areas mentioned by health workers when asked to recall

and describe a normal counselling session with a mother/caregiver of a child who is

not growing or is malnourished. The majority of health workers interviewed reported

talking with the mother/caregiver about the importance of a varied diet and the

amount and frequency of feeding appropriate for an infant or child. Very few health

workers set goals with the mother or caregiver and most did not check the mothers’

or caregivers’ understanding of what advice was given during the counselling session.

Goal-setting and checking that the mother/caregiver has understood what was

discussed during a counselling session are two very important aspects of IYCF

counselling that are known to improve adoption of new behaviours and promote

change.

Whereas the results may not give the full picture since the methodology of

retrospectively recalling is less accurate than actual observation of health workers,

the results nevertheless indicate that practices associated with good counselling skills

were not reported often and may therefore raise issues regarding the quality of care.

2.11.4 Self-reported ability and knowledge to address

nutrition problems

The results of the self-assessed ability of health workers to advise breastfeeding

mothers in the context of HIV during a counselling session is summarised here. The

results given here represent the average responses expected according to five

predetermined components. These components were:

Questions to ask during the counselling session;

Signs to assess the health of mother and infant;

Communication aspects;

Giving advice during counselling; and

Adherence to the 2010 IYCF guidelines.

Table 16, below, summarises the criteria used to assess health worker knowledge

under the five different assessment components.

64


Table 16: Criteria used to assess health worker knowledge in counselling a mother in the context of HIV

Number of

criteria Questions to ask

Signs to look For

Communication aspects

Giving advice

Adherence to IYCF guidelines

1 Questions about feeding Feeding practices

Non-verbal communication

Accepting the mother’s feelings

Exclusive breastfeeding for 0-6 months

2 Questions about mother and baby health

Breast health

Use of open-ended questions

Praising the mother’s efforts

Introduction of complementary feeding at 6 months

3 Questions about mother’s ANC attendance

Growth monitoring and weight gain

Showing interest in the mother

Practical help to the mother

Continued breastfeeding to 12 months

4 Questions about family planning

Clinical signs in both mother and infant

Reflecting back

Provision of little relevant information

5 Questions about the mother’s infant feeding experience

Clinical dietary history

Showing empathy

Use of simple language

6 Questions about the mother’s family and socio-economic situation

Non-judgmental behaviour

Practical suggestions

7 Questions about mother’s recruitment/inclusion into a PMTCT programme in her area

Figure 16, below, presents the national average of the results of this analysis.

Figure 16: National average of self-assessed health worker knowledge in counselling mothers on

breastfeeding in the context of HIV

65


Figure 17: Number of facilities providing counselling and support for appropriate complementary feeding, and the reported content of messages

Out of 31 health facility managers who were interviewed, 29 (96.7 per cent) indicated

that they provide counselling and support for appropriate complementary feeding.

Fifteen out of 31 respondents indicated that they provide interventions on timely

introduction of complementary foods at six months. The counselling and support

provided for IYCF practices that promote dietary diversification, minimum adequate

diet and minimum meal frequency, provision of fortified supplementary foods as

needed, and the prevention of infectious disease through the promotion of good

hygiene practices were reportedly provided by less than 30 per cent (i.e., nine or

fewer respondents) in the health facilities whose health facility managers were

interviewed. These practices are critical to ensuring that infants and young children

receive complementary feeds that are not only adequate in quantity but are also of

the appropriate and adequate quality provided at the correct frequency during the

day in a safe way. These findings point to an urgent need to strengthen counselling on

infant and young child feeding and ensure all components of counselling in

complementary feeding are comprehensively covered.

2.11.5 Counselling and support for appropriate breastfeeding

and the reported content of messages provided

66


Figure 18: Percentage of facilities providing counselling and support for appropriate breastfeeding, and the reported content of messages

All 31 respondents (i.e., 100 per cent) reported that counselling and support for

appropriate breastfeeding was provided in their health facilities. However, (0%) none

of the facilities provided counselling and support on the early initiation of

breastfeeding within one hour of birth, and only 68 per cent (i.e., 21 respondents)

indicated that they provide counselling and support on exclusive breastfeeding up to

six months. Only 25 per cent provided counselling and support on continued

breastfeeding to two years and beyond. The content of the counselling on

breastfeeding at health facility levels needs to be reviewed so as to fully reflect the

guidelines on counselling and support on breastfeeding, encompassing early initiation

and spanning through to the practice of continued breastfeeding.

67


2.12 MANAGEMENT OF SEVERE ACUTE MALNUTRITION (SAM)

AND THE ADVICE AND TREATMENT PROVIDED

Figure 19: Number of facilities that treat SAM (with and without complications) and content of treatment and advice

Twenty six of the 31 responding health facility managers interviewed reported that

there was an ongoing intervention to manage children with severe acute malnutrition

(SAM). Twenty of the 31 indicated that they had interventions to treat children with

SAM who also presented with complications, while 21 health facility managers

indicated that they had an intervention to treat children with SAM without

complications. However, thirty percent or less (i.e., <9/31) of the health facilities had

counselling and support practices or interventions that could adequately address SAM

or its effects; interventions such as exclusive breastfeeding until six months and

continued breastfeeding beyond two years, or nutritional rehabilitation with locally

available foods or the use of ready-to-use therapeutic foods (RUTF), were not

mentioned as part of the management of SAM.

68


2.12.1 Management of SAM and MAM and the availability of

adequate and relevant supplies

Figure 20: Number of facilities that are doing SAM management, and availability of relevant material and supplies

Figure 20, above, illustrates the number of facilities reporting the supplies in stock for

the management of SAM and/or MAM. None of the health facilities reported having

stocks of supplies needed for in-patient treatment, since they have not started with

the implementation of the clinical in-patient management of SAM. Only six facilities

out of 26 have RUTF. Fifteen of 26 facilities that reported SAM management did not

have the relevant equipment to measure height or length. Further assessment is

required to understand the reasons between the gap in the availability of equipment

and the interventions undertaken at health facilities.

69


2.12.2 Management of moderate acute malnutrition and the

advice given

Figure 21: Percentage of respondents on management of moderate acute malnutrition (MAM) and advice

In a similar fashion to the management of severe acute malnutrition (SAM), fewer than half

of the respondents in the health facilities reported covering all topics necessary to provide

adequate counselling and support for the successful management of MAM. No respondents

mentioned continued breastfeeding up to 2 years or beyond or clinical care as part of the

successful management of MAM.

70


2.12.3 Implementation of key nutrition activities

recommended for women

Figure 22: Percentage of facilities that implement key nutrition interventions recommended for women.

Twenty-nine of 31 (94 per cent) of health facility managers reported providing iron

and folic acid supplementation interventions for pregnant women. Additionally, 55 per

cent of health facility managers replied to having interventions that provide the

appropriate care of women with low BMI. Fewer than half of the health facilities

managers reported having calcium supplementation interventions for the control and

prevention of pre-eclampsia and eclampsia during pregnancy, or folic acid

supplementation or the provision of iodine supplement to pregnant and lactating

women.

71


2.12.4 Nutrition-sensitive interventions recommended for

women carried out at facility level

Figure 23: Number of nutrition-sensitive interventions implemented at facility level

Figure 23, above, gives the results of reported nutrition-sensitive interventions

ongoing at the health facilities enrolled in the survey. One hundred percent of health

facility managers reported interventions on the enrichment of food.

72


2.13 NUTRITION EDUCATION CARRIED OUT AT HEALTH

FACILITIES

Figure 24: Nutrition education

Figure 24, above, illustrates the nutrition education reported by health facility managers

interviewed during the NLSA. Thirty out of 31 health managers reported that nutrition

education was undertaken in their health facilities. However fewer than 50 per cent of the

health facilities were providing health education on healthy eating for the prevention of

under-nutrition or the prevention of micronutrient deficiencies, or were carrying out

education on the promotion of health dietary practices and physical activity for prevention

of overweight/obesity and NCDs. The finding that there was limited promotion of healthy

eating for the prevention of under-nutrition or for the prevention of micronutrient

deficiencies is in line with the low level of responses around dietary diversification in

complementary feeding or in the management of SAM. The reason for this gap warrants

further investigation so as to better equip health workers at facility level with the skills and

knowledge required to prevent under-nutrition and promote healthy diet and lifestyles, so

as to address the detrimental effect of malnutrition (both over- and under-nutrition).

73


2.13.1 Health worker capacity, motivation and time to

conduct nutrition duties

Figure 25: Health workers’ responses regarding time to undertake nutrition duties

Sixty-five percent of health workers interviewed reported they did not have adequate

time to carry out nutrition duties. The health worker cadre most likely to be

responsible for nutrition duties is the nurse. The demands on the nurse are

considerable considering there is no separate cadre of health worker to absorb

specific nutrition duties. However most of what is required of the nurses regarding

nutrition is within the scope and practice of their job. For example, under antenatal

care, the provision of maternal nutrition information and counselling is part of the

standard package of ANC.

According to facility managers, nutrition education and counselling take place in

different settings, ranging from hospitals and clinics. The majority of nutrition-related

services and tasks are integrated into other health programmes. Table 17, below,

outlines how nutrition is integrated into the various different health programmes.

Yes35%

No65%

Health workers have adequate time to do nutrition duties

74


Table 17: Where does nutrition education and counselling take place?

Programme How is nutrition integrated?

Integrated Management of Neonatal and Childhood Illnesses

Information given about breastfeeding; attachment positioning etc., when infant is brought for immunization

Infant/child growth is monitored

Community outreach does nutrition and infant feeding promotion

Assessment of micronutrient deficiency, e.g., anaemia

Nutrition treatment according to flow chart

Maternal and Child Health

Nutrition information given during ANC and PNC

Breastfeeding promotion; cooking demonstrations are given

Mother advised on feeding according to baby’s age

Health education on nutrition and assessment with GMP, complementary feeding and personal hygiene

Maternal weight gain, health education

Adolescent Health

Nutrition advice for mothers

Screening

School health education programme

School feeding programme

HIV-related diseases

When clients present to ART clinics they are given advice about nutrition, for example they are given advice on how to eat and what to eat (eat locally-available foods)

Women and children are screened for malnutrition and eligibility for NACS

Given advice and information about infant feeding in the context of HIV during ANC

Other Growth monitoring and promotion, ANC, PNC

Education, counselling on nutrition

This summary of how nutrition is integrated into other health programmes does not

accurately reflect the current situation across all health facilities and services,

however. The inclusion of nutrition is ad hoc and inconsistent across the nation.

Where NACS is operating, the quality and standardisation of services is much

stronger.

With regard to who is responsible for nutrition and whether those performing nutrition

tasks are adequately trained, the following table provides a summary of responses

from the various health workers across the nation.

75


Table 18: Summary of health workers’ responses regarding nutrition tasks

Question Response

Who is responsible for nutrition group education in your facility?

Nurses

Registered nurse with an enrolled nurse designated for training/student nurses

Doctors

Nurses from maternity, premature unit and paediatric ward

TB field promoters, community counsellors, volunteers

What relevant training does he/she have?

Nurses training

IMNCI and IMAI training, IMAM training

E/N knowledge from training, NACS, HIV/TB and hygiene training

Where are sessions held?

Waiting area within the health facility

In-patients’ room

Paediatric unit room

Maternity unit

Premature unit

How often are sessions held? Randomly

No set times

What topics are covered during sessions?

Balanced diets

Different types of food and food preparation

What foods to give and how frequently, and follow up

Hand hygiene

Feeding options

Breastfeeding

TB, HIV, nutrition

Which tools or materials are being used? Oral health information

No aids or IEC materials used

Who is participating in sessions? Approximately how many receive nutrition group education per month?

Women: approximately 20 per group (reported by one health facility only)

Nurses are the primary cadre of health worker that provides nutrition services and

counselling. They are not trained specifically in nutrition, however some have

received training on some nutrition services such as NACS and growth monitoring and

promotion. The responsibility of providing nutrition services lies with all health

workers and therefore there is a risk of low accountability and follow up. The range of

services and nutrition counselling offered is delivered in an ad hoc manner; staff

members do not use or have access to visual or written IEC materials.

76


2.14 MANAGEMENT SYSTEMS

The primary health care supervisor and the principal medical officer are the officers

responsible for nutrition implementation at district level.

Nutrition information is collected as part of the national Health Information System

from the MoHSS. The system has been in use since 1992 and is managed by the Health

Management Information Section of the ministry. This section is under the Directorate

of Planning.

The data flow involves the collection of the data elements on forms at health facility

level; this information is passed onto the health district office for data capture.

Following this, data are then sent electronically to the regional health office for data

checks prior to forwarding the data to the national-level office. The data collected

are used at all levels to check patient attendance and health services rendered at

primary health care, outpatient, and in-patient departments of the health system, in

addition to which it is used to produce annual reports and national-level reporting.

Quality control to ensure that data captured are accurate and reliable is done at all levels.

In addition to this, the NDHS also collects data related to nutrition, which constitutes

very useful information for planning and implementation of nutrition programmes.

This is complemented by nutrition surveys (which are done rarely). For example a

micronutrient survey was done in 1992 to identify the major micronutrient

deficiencies in the country. Since then however, there has not been a systematic

documentation of the micronutrient levels in the country.

2.14.1 Nutrition information and availability of nutrition data

Nutrition information and indicator collection, and use at national level The results presented here about the collection of data and nutrition information and

its use at national level were collected from two line ministries, two NGOs, and one

tertiary institution. Table 19, below, outlines how the data are collected, the

frequency of data collection, the indicators collected, and how the data are used and

shared. In summary, MoHSS at national level collects routine nutrition data at five-

year intervals in national surveys, the target group being under fives. Monthly data

that are collected by MoHSS are data about the treatment of all children, including

HIV+ children. The data are primarily used for planning purposes and are disseminated

in consensus workshops and meetings with the communities.

The Ministry of Education collects school performance and enrolment data on a

quarterly basis, providing quarterly reports that are used for programme monitoring

purposes. The NGOs reported that their data are collected fortnightly to once a

month. The indicators collected were anthropometric and food consumption data. The

members of the communities that these NGO serve are the target group. The data are

used for planning and monitoring purposes and are disseminated through meetings

with line ministries, RACCOCs and CACCOCs on a monthly or quarterly basis. The

Polytechnic of Namibia was the academic institution interviewed and they indicated

that they used UN publications for teaching purposes.

77


It was observed, however, that the stakeholders interviewed are not using relevant

nutrition data and although the indicators were relevant to the mandate of their

agency, they did not address adequately nutrition problems and its causes. Indicators

collected are relevant to country context. It was also found that there was sharing of

data and reports with other levels and with partners. Gaps found were that the

relevant nutrition surveys are not available, and indicators relevant to intervention

programmes are not systematically collected.

Table 19: Summary of the information on nutrition indicators, use of data and receipt of feedback, and the use of feedback at national level in Namibia

AGENCY Routine data? Y/N

How are data collected and

collated

Frequency of data

collection

Nutrition indicators collected

Target group How is

information shared?

How are data used

MoHSS Yes Surveys and routine data; manually and electronically

Every five years

Stunting

Wasting Under 5

Environmental health programme meeting with communities

MoHSS Yes Surveys; manually and electronically; publications by UN

Every five years

Wasting

Stunting

Underweight

Under 5 Sensitisation and dissemination workshop

Planning

MoHSS Yes Routine data electronically collected

Monthly Treatment of HIV + children

PLHIV

MoE Yes Routine data manually collected

Quarterly

School

enrolment

School performance

All school-going children Grades 1 – 7

Quarterly summaries are provided

Monitoring

DAPP Yes Routine data manually collected

Twice a month

Food consumption

Community members

Monthly and Quarterly reports

Planning

Situation

Analysis

Monitoring

Catholic AIDS Action

Yes Routine data manually collected

Monthly BMI OVC PLHIV

RACCOC and SPM Line Ministries

Planning

Monitoring and Evaluation

Polytechnic of Namibia

Yes Other publications by UN

Teaching

Nutrition information and indicator collection and use at regional level To gain a fuller understanding of the collection, use and exchange of nutrition data and

indicators in the country, it became necessary to provide a regional synopsis. Information

on nutrition indicators and the feedback loops involved was collected for 12 of the 13

regions of Namibia. Interviews were not undertaken in Omaheke Region as the person

responsible for nutrition was not available for interview. Anthropometric data is collected

in all the health facilities interviewed in the 12 responding regions. Data is then channelled

to the regional level and this is done on a monthly basis. The reasons for data collection

were cited as planning, monitoring, and community sensitisation. It was indicated that

health facilities were given feedback on the data they collected in Ohangwena, Oshana,

Otjozondjupa, Omusati, Kunene and Hardap regions. A challenge that was cited was that

the sharing of data and information about the data from national level to regional or

district level was very limited. Table 20, below, outlines the results reported.

Nutrition information and indicator collection, and use at by NGOs at regional level

78


Information about the collection, use and dissemination of data was collected from

NGOs in six regions. The main nutrition indicators collected were related to

anthropometry and growth monitoring, and food security. There was a major HIV

focus as it was reported that OVCs or PLHIV were the target groups in four of the six

reporting regions. Emergency-affected communities and pregnant and lactating

mothers were also targeted. Collection of data varied from a monthly to an annual

basis. Data were shared between stakeholders, which were primarily related line

ministries. NGOs also reported receiving information from other stakeholders. The

types of data received included the Namibia Demographic and Health Survey, and the

Poverty Reduction Strategy reports for the regions. The shared information was used

for purposes of planning, fund raising through proposal writing, advocacy, and

monitoring. Table 21, below, outlines the results obtained from NGOs.


Table 20: Summary of the information on nutrition indicators, use of data and receipt of feedback, and the use of feedback in the health system of the regions of Namibia

Region Nutrition indicators Frequency

of data collection

Use Administrative

-level data sent to

Feedback loop and purpose

Do district give feedback to Health

Facilities

Nutrition information from

regional or national level

Caprivi Underweight Monthly Planning Monitoring

Regional Did not know No Sporadic

Erongo Underweight Monthly Planning Regional No Yes No

Hardap Underweight Monthly Planning Regional

Yes Any problem with data and to identify priority areas

Yes, meetings to discuss problems

Any new report or guideline

Karas Underweight Monthly Community sensitisation

Regional Yes. Planning and monitoring

No, do not have a printer Sporadic

Kavango Weight, height, MUAC Monthly Reporting Regional Yes Yes Sporadic

Khomas Underweight Monthly Planning Regional

No. No one responsible for nutrition programme

No Done only for reporting purposes

Kunene LBW, underweight, HBC giver trained, # clients counselled, obesity

Monthly Monitoring severe malnutrition

Regional No Yes, meeting to discuss problems

Any new report or guideline

Ohangwena Underweight, overweight, MUAC

Monthly Planning Regional No Yes, correct mistakes, find out reasons for malnutrition

No information

Omusati Underweight Monthly

Planning Regional No Yes, monthly meetings Guidelines, policies, protocols

Oshana Underweight, MUAC Monthly

Planning Regional No Yes, reporting, monitoring, support

Sporadic

Oshikoto Underweight Monthly Did not know Did not know Did not know Did not know Did not know

Otjozondjupa Weight, height, MUAC Monthly Planning Monitoring

Regional Yes Yes, verbal, supervisory visits

Sporadic


80

Heig

ht/

Stu

nti

ng

Table 21: Summary of the information on nutrition indicators, use of data and r eceipt of feedback, and the use of feedback by NGOs at regional level

Region

NGO collect routine data? Y/N

Nutrition Indicators collected

Target group Frequency of data

collection

With whom share

information

Ever received info from

other stakehold

ers

If yes, describe How is data from

other sources used

Caprivi Yes

Food security, parenting map

Emergency-affected communities Caregivers

As required, use data as monitoring tool

Other stakeholders

Yes

NDHS Poverty assessment done by Regional Council in 2007/8

Planning, proposal writing, monitoring, targeting

Hardap Yes Underweight OVC PLHIV

Monthly Line ministries Yes Regional committees sharing information from MHSS & MGECW

Planning

Karas Yes

BMI Weight Height MUAC

OVC Quarterly Other stakeholders

No Planning, advocacy, monitoring

Kunene Did not know

Did not know Did not know Did not know Did not know Did not know

Did not know Did not know

Omaheke Yes Food consumption

OVC PLHIV

Monthly None Yes Data not used

Oshana Yes BMI OVC Annually Other stakeholders

Did not know

Sharing of information

Otjozondjupa Yes

Weight Height Blood pressure

Children Pregnant women

Monthly None No Monitoring

81


Heig

ht/

Stu

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ng

2.14.2 Communication of nutrition information to communities

Provided below in Table 22 is a summary of the ways in which information is shared

with communities by health workers in the regions. The health workers did not

perceive any barriers to communication of nutrition issues to the communities they

serve. In addition, this table provides additional insight as to the existing channels of

nutrition information and what can be built upon.

Table 22: Summary of methods of information dissemination to communities in the regions

Region Are nutrition messages

communicated to communities? Y/N

If yes, describe how

Caprivi Yes Radio programmes

Erongo Yes Media; community meetings; church; school

Hardap Yes Health education to patients; radio programmes

Karas Yes Outreach programmes

Kavango Yes Outreach programmes; radio programmes; posters and health education to patients

Khomas Yes Training of community volunteers; community meetings

Kunene Yes Nutrition education to patients; at ANC

Ohangwena Yes Training of community volunteers

Omusati Yes Health education to patients, outreach programmes, community meetings

Oshana Yes Outreach programmes

Oshikoto Yes Health education to patients

Otjozondjupa Yes Health education to patients; community gardens

2.14.3 Supplies

Data about stocks and supplies were collected from 31 facilities nationwide.

Tables 23 and 24 provide a summary of the types of facilities visited and health

workers interviewed.

Table 23: Number of health facilities visited

Type of facility Number

Clinic 9

Health centre 4

District hospital 13

Intermediate referral hospital 3

National referral hospital 1

Table 24: Number of health workers interviewed


82

Health worker category Number of

health workers

Enrolled nurse 1

Registered nurse 5

Doctor 1

Medical officer 1

Matron 5*

Nurse-in-charge 4**

Nurse manager 6***

Chief control registered nurse 2

Principal registered nurse 3

Manager 1

PHC coordinator 1

Nurse 1

* 2 in acting capacity

* 1 in acting capacity

***3 in acting capacity

83


2.15 IEC MATERIALS

There were very low stocks of IEC materials found at the health facilities visited.

Figure 26, below, summarises the results of the number of respondents who reported

stocks of IEC materials.

Figure 26: IEC materials available at facility level

Figure 26, above, summarises the number of facility managers that reported that they

had the IEC materials represented in the figure above. Twenty one of the 31

responding health facility managers indicated that they had stocks of IEC materials on

hand-washing with soap in stock. IEC materials on family planning and spacing were


84

reported in stock by 12 respondents and 10 respondents reported stocks of IEC

materials covering exclusive and continued breastfeeding. Notably, of the 19 different

IEC materials topics, nine were not stocked by any of the health facilities visited.

These results point to a gap in the availability of information materials that will

inform, educate and communicate vital health messages on infant and young child

feeding; antenatal, postnatal and maternal health; infection prevention and control;

the prevention of micronutrient deficiency; issues on PMTCT and HIV; and IYCF .

2.16 PROTOCOLS AND GUIDELINES

There was very limited availability of protocol or guideline material found at the

health facilities visited. Figure 27, below, gives the results of the number of health

facility managers that reported the availability of the WHO 2003 Guidelines for the

clinical inpatient treatment of severely malnourished children, the NACS programme

protocols, or other protocols in the health facilities.

Figure 27: Availability of protocols/guidelines at health facilities

In the figure above, 18 of 31 (i.e., 58 per cent) of health facility managers indicated

that they were not in possession of any protocols; two health facility managers had a

copy of the WHO 2003 Guidelines for the clinical inpatient treatment of severely

malnourished children and ten had copies of the NACS programme protocols.

Figure 28, below, gives the results of the number of health facility managers that

reported the availability of protocols on child nutrition interventions in health

facilities.

85


Figure 28: Number of respondents reporting protocols related to child nutrition-related interventions in stock in health facilities

Figure 29, below, gives the results of the number of health facility managers that

reported the availability of protocols on women’s nutrition interventions and infection

control interventions in health facilities.


86

Figure 29: Number of health facility managers that reported the availability of stocks of protocols on women’s nutrition interventions and infection control interventions in health facilities

Only a few health facilities had protocols on nutrition interventions recommended for

women as can be seen in Figure 29, above. The five protocols on nutrition

recommended for women that were found in one or more health facilities during the

survey were on iodine supplementation; nutrition care and support for pregnant and

lactating women; nutrition care and support in emergencies; prevention of malaria in

pregnancy; and deworming protocols. These findings illustrate major gaps in necessary

guidelines to support nutrition interventions recommended for women. The reasons for

the gaps in the availability of protocols across the board warrant further investigation

so as to best understand how to most effectively meet this very evident need.

87


PART III: DISCUSSIONS AND CONCLUSIONS

There is strong political commitment to nutrition in Namibia. This was expressed by

the declaration of two ‘nutrition decades’ (1993-2012) by the GRN; development of

food security and nutrition programmes that embodied the food security and nutrition

policy for Namibia; and establishment of the Food Security and Nutrition Council,

Secretariat, and technical committees with regional representation and the

development and dissemination of the food security and nutrition action plans. In

addition to these documents, each line ministry also has nutrition-specific and/or

nutrition-sensitive policies and strategic plans and guidelines. In 2010, the Right

Honourable Prime Minister of Namibia launched an alliance for improved nutrition in

the country, which brings together multiple stakeholders that include line ministries,

UN agencies, bilateral and multilateral organisations, the private sector, and NGOs.

The national-, regional- and district-level respondents have identified under-nutrition

(i.e., underweight and wasting) as the major nutrition problem in the country.

However, obesity, micronutrient deficiency, and stunting were not perceived as public

health problems in the country. This highlights the lack of awareness and

understanding on the double burden of malnutrition which is emerging in most

developing countries, including Namibia. This could be attributed to lack of

communication of the existing nutritional problems in user-friendly language that the

general public can understand.

Currently, relevant line ministries and some NGOs are implementing nutrition-related

activities ranging from food security to implementation of community-based nutrition

initiatives. This should be capitalised upon in order to expand in terms of geographical

coverage and extent of interventions to support the national nutrition response to

reduce malnutrition in Namibia. Nutrition activities in the country are sector-specific,

with little or no coordination or sharing of information between sectors.

The human resources for nutrition are limited, with very few nutritionists in the

country and no nutritional focal persons in the regions and districts of Namibia. This

calls for strengthening of the in-country and out of country training programmes for

nutrition, and exploring innovative ways of building the capacity of work forces and

enhancing the provision of necessary protocols/guidelines and IEC materials to enable

them to implement and manage nutrition-related programmes in the country.

The financial resources and allocation to nutrition by the government sectors and

partners is either inadequate or non-existent. The scarcity of resources is worse for

community-based nutrition interventions. There is a need for creating a budget line for

nutrition, and an allocation of more resources by the GRN and development partners.

Nutrition information in the country is heavily reliant on the NDHS and other surveys.

The continuous flow of key nutrition information is weak and needs strengthening to

support timely, informed decision making across sectors in nutrition.


88

The assessment revealed that there is a need for developing and disseminating

appropriate IEC materials for nutrition using a life-cycle approach adapted across all

relevant sectors and partners to be used at all levels.

Although Namibia has a strong political commitment and very comprehensive policies

and guidelines for nutrition, their translation to concrete actions is hampered by a lack

of adequate human and financial resources for nutrition and weak coordination

mechanisms at various levels of the system. This calls for a concerted effort to

conduct advocacy at all levels in order to place nutrition at the centre of

development.

The excellent relationship between government and development partners and other

stakeholders should be capitalised upon to create a broader government, development

partners and stakeholders coordination mechanism in the country.

Recommendations

1. The revision of the National Food and Nutrition Policy to guide government and

partners in delivering evidence-based and cost effective food and nutrition

interventions.

2. The enactment and subsequent development of regulations to enforce the international

code of marketing on breast milk substitutes in order to protect, promote and support

exclusive breastfeeding.

3. The enforcement of salt iodization legislation and the development of micronutrient

supplementation guidelines.

4. The creation of posts for nutritionists at all levels; allocation of adequate human and

financial resources for nutrition by both the government and development partners.

5. There is a need for developing the capacity of the workforce for nutrition through

short-, medium- and long-term training strategies to address the shortage of nutrition

experts in the country.

6. The existing policies, strategies and guidelines on nutrition should be well

communicated and operationalized to bring about the desired results on the ground.

7. Development of a multi-sectoral approach to nutrition problems, with clear

descriptions of responsibilities for the relevant sectors and a

revitalisation/strengthening of the coordination mechanisms for nutrition at all levels.

8. The nutrition information and surveillance systems should be streamlined to the

existing structures of the line ministries with distinct indicators for each sectors to

collect, collate, analyse and utilise the information for evidence-based policy decisions

and programming. In the long term, government should utilise existing mechanisms to

have one Nutrition Information System for the whole nation.

9. Evidence-based and effective nutrition interventions should be scaled up by all relevant

sectors, and partners should support the strategic plans of line ministries and the

monitoring and evaluation of the programmes.

10. A systematic advocacy and targeted information, education and communication

strategy for nutrition should be designed and implemented to promote and support

healthy lifestyles and environments. All stakeholders, including the media, should

89


support its implementation to improve the health and nutritional status of the

population.

11. An enabling environment needs to be created for promoting research for innovation and

documentation of best practices, and to positively influence policy and programmatic

decisions.

12. Creation and/or strengthening of coordination mechanisms among sectors,

development partners and other stakeholders supporting food and nutrition

interventions at all levels.


90

PART IV: REGIONAL PROFILES

This section of the report present profiles developed for all 13 regions separately. The

profiles present a summary of the available information on the nutrition status

indicators by region (developed from the findings of the NLSA conducted in all 13

regions).

The value of each indicator was considered separately and was classified according to

the values below:

Value of the indicator Category Colour code

75-100 Strong

50-75 Medium

0-50 Weak

The expected value of each indicator is considered to be strong (colour code: green).

Regional profiles are presented in alphabetical order:

1. Caprivi Region

2. Erongo Region

3. Hardap Region

4. Karas Region

5. Kavango Region

6. Khomas Region

7. Kunene Region

8. Ohangwena Region

9. Omaheke Region

10. Omusati Region

11. Oshana Region

12. Oshikoto Region

13. Otjozondjupa Region

91


1. Regional profile: Caprivi Region

Nutritional problems: children under the age of five years:

Programme-related issues:

INDICATOR Regional average

Regional situation

National average

CA

PA

CIT

Y T

O A

CT

Willingness to contribute to scale up of nutrition 57.1% Medium 69.6%

Existence of senior-level forum for coordination of nutrition strategies/interventions

100% Strong 100%

Specific and appropriate nutrition policies, strategies and action plans

12% Weak 48.8%

Integration of nutrition actions into other health and non-health policies (HIV, IMNCI, MCH)

33% Weak 45.2%

Budget availability for nutrition 87.5% Strong 85.6%

Existence of financial resources for nutrition among partners

20% Weak 45.3%

Involvement of partners to plan for and support scaling up nutrition

88% Strong 70.6%

Adequate legislation is enacted and enforced (International Code MBMS)

12% Weak 13.8%

Awareness and adherence to nutrition protocols By Health worker

0% Weak 46 %

Supervision of nutrition interventions by MoHSS level 65% Medium 50.4%

Frequency of supervision for nutrition interventions 55% Medium 50%

Support to facility level in the region by MoHSS level 67% Medium 53.2%

Summaries of nutrition data made available to regions 24% Weak 29.8%

Status of MBFI certification 0% Weak 0%

Appropriate number of skilled staff at each level of service delivery for scope of work provided

24% Weak 24.8%

Availability of follow up training at all levels 50% Medium 72.6%


92


Regional situation

National average

CA

PA

CIT

Y T

O A

CT

Training on nutrition received by staff

Community 87.5% Strong 50.3%

District 88% Strong 79.7%

Regional 87.5% Strong 82.4%

Health workers have correct knowledge on nutrition protocols

72% Medium 58.2%

Health workers have skills to implement nutrition counselling

17% Weak 35.2%


50% Medium 29.8%


50% Medium 33.5%

Satisfaction of staff at all levels with regards to management structures, monitoring, coverage and quality of service

44% Weak 25.8%

Integration of nutrition protocols into other primary maternal, child health services

80% Strong 52.7%

Collection of relevant nutrition-related data 100% Strong 92%

Use of data for decision-making 87.5% Strong 69.2%

Adequate information flow and feedback 40% Weak 46.9%

Budget line for nutrition (0%) Weak 19.8%

Availability of updated IEC material 39% Weak 15.8%

Provision of essential supplies and equipment at health facilities

60% Medium 66.8%

Community support for nutrition programmes (volunteers, support groups, home-based workers, outreach activities)

88% Strong 61.9%

Direct funding available to community-based organisations for nutrition activities

4% Weak 3.4%

93


2. Regional profile: Erongo Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT

Willingness to contribute to scale up of nutrition 75% Strong 69.6%


100% Strong 100%


24% Weak 48.8%


66% Medium 45.2%

Budget availability for nutrition 88% Strong 85.6%


49.5% Medium 45.3%


87% Strong 70.6%


12% Weak 13.8%

Awareness and adherence to nutrition protocols By Health worker 0% Weak 46%

Supervision of nutrition interventions by MoHSS level 40% Weak 50.4%

Frequency of supervision for nutrition interventions 40% Weak 57%

Support to facility level in the region by MoHSS level 0% Weak 53.2%




24% Weak 24.8%

Availability of follow up training at all levels 88% Strong 72.6%


94


Regional situation

National average

CA

PA

CIT

Y T

O A

CT


Community 75% Strong 50.3%




70% Medium 58.2%


8% -25% Weak 35.2%


0% Weak 29.8%


70% Medium 33.5%


0% Weak 25.8%


0% Weak 52.7%


Use of data for decision-making 88% Strong 69.2%


Budget line for nutrition 20% Weak 19.8%



43% Weak 66.8%


40% Weak 61.9%


0% Weak 3.4%

95


3. Regional profile: Hardap Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT



100% Strong 100%


87.5 Strong 48.8%


100% Strong 45.2%



49.5% Medium 45.3%


87.5% Strong 70.6%


12% Weak 13.8

Awareness and adherence to nutrition protocols By Health worker 57% Medium 46 %

Supervision of nutrition interventions by MoHSS level 75% Strong 50.4%




Status of MBFI certification 0 Weak 0


12% Weak 24.8%



96


Regional situation

National average

CA

PA

CIT

Y T

O A

CT


Community 20% Weak 50.3%

District 80% 79.7% 79.7%

Regional 85% 82.4% 82.4%


52% Medium 58.2%


75-83% Strong 35.2%


29% Weak 29.8%


29% Weak 33.5%


50% Medium 25.8%


87.5% Strong 52.7%



Adequate information flow and feedback 50% Medium 46.9%




60% Medium 66.8%


87.5% Strong 61.9%


0% Weak 3.4%

97


4. Regional profile: Karas Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT



100% Strong 100%


82% Strong 48.8%


66% Medium 45.2%

Budget availability for nutrition 75% Strong (MoA)

85.6%


80% Strong 45.3%


50% Medium 70.6%


12% Weak 13.8

Awareness and adherence to nutrition protocols by Health worker 66% Medium 46 %



Support to facility level in the region by MoHSS level 100% Strong 53.2%




14% Weak 24.8%



98


Regional situation

National average

CA

PA

CIT

Y T

O A

CT






58% Medium 58.2%


25-33% Weak 35.2%


33% Weak 29.8%


0% Weak 33.5%


38% Weak 25.8%


80% Strong 52.7%




Budget line for nutrition 80% Strong 19.8%



80% Strong 66.8%


88% Strong 61.9%


4% Weak 3.4%

99


5. Regional profile: Kavango Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT

Willingness to contribute to scale up of nutrition 83.3% Strong 69.6%


100% Strong 100%


83% Strong 48.8%


56% Medium 45.2%



20% Weak 45.3%


20% Weak 70.6%


12% Weak 13.8

Awareness and adherence to nutrition protocols By Health worker

100% Strong 46 %







20% Weak 24.8%



100


Regional situation

National average

CA

PA

CIT

Y T

O A

CT




Regional 80% Strong 82.4%


64% Medium 58.2%


25-33% Weak 35.2%


50% Medium 29.8%


40% Weak 33.5%


30% Weak 25.8%


70% Medium 52.7%

Collection of relevant nutrition-related data 50% Medium 92%

Use of data for decision-making 24% Weak 69.2%





90% Strong 66.8%


40% Weak 61.9%


4% Weak 3.4%

101


6. Regional profile: Khomas Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT



100% Strong 100%


22% Weak 48.8%


22% Weak 45.2%



70% Medium 45.3%


63% Medium 70.6%


12% Weak 13.8

Awareness and adherence to nutrition protocols by Health worker

20% Weak 46 %







23% Weak 24.8%



102


Regional situation

National average

CA

PA

CIT

Y T

O A

CT




Regional 57% Medium 82.4%


57% Medium 58.2%


25-33% Weak 35.2%


17% Weak 29.8%


25% Weak 33.5%


0% Weak 25.8%


30% Weak 52.7%







84% Strong 66.8%


40% Medium 61.9%


4% Weak 3.4%

103


7. Regional profile: Kunene Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT

Willingness to contribute to scale up of nutrition 50% Medium 69.6%


100% Strong 100%


24% Weak 48.8%


0% Weak 45.2%



65% Medium 45.3%


60% Medium 70.6%


12% Weak 13.8


33% Weak 46 %







45% Weak 24.8%

Availability of follow up training at all levels 40% Weak 72.6%


104


Regional situation

National average

CA

PA

CIT

Y T

O A

CT






60% Medium 58.2%


25-42% Weak 35.2%


25% Weak 29.8%


75% Strong 33.5%


8% Weak 25.8%


50% Medium 52.7%







43% Weak 66.8%


80% Strong 61.9%


12% Weak 3.4%

105


8. Regional profile: Ohangwena Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT



100% Strong 100%


14% Weak 48.8%


100% Strong 45.2%

Budget availability for nutrition (MAWF)78% Strong 85.6%


30% Weak 45.3%


82% Strong 70.6%


12% Weak 13.8


46% Weak 46 %







22% Weak 24.8%



106


Regional situation

National average

CA

PA

CIT

Y T

O A

CT






41% Weak 58.2%


58% Medium 35.2%


50% Weak 29.8%


0% Weak 33.5%


17% Weak 25.8%


24% Weak 52.7%




Budget line for nutrition 75% Strong (MAWF)

19.8%



60% Medium 66.8%


40% Medium 61.9%


4% Weak 3.4%

107


9. Regional profile: Omaheke Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT



100% Strong 100%


23% Weak 48.8%


0% Weak 45.2%



22% Weak 45.3%


83% Strong 70.6%


12% Weak 13.8


0% Weak 46 %

Supervision of nutrition interventions by MoHSS level 75% Strong 50.4%



Summaries of nutrition data made available to regions 66% Medium 29.8%



70% Medium 24.8%



108


Regional situation

National average

CA

PA

CIT

Y T

O A

CT






50% Medium 58.2%


33-58% Weak 35.2%


50% Medium 29.8%


33% Weak 33.5%


22% Weak 25.8%


50% Medium 52.7%







87% Strong 66.8%


83% Strong 61.9%


4% Weak 3.4%

109


10. Regional profile: Omusati Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT

Willingness to contribute to scale up of nutrition 60% Medium 69.6%


100% Strong 100%


79% Strong 48.8%


33% Weak 45.2%



23% Weak 45.3%


60% Medium 70.6%


12% Weak 13.8


22% Weak 46 %







24% Weak 24.8%



110


Regional situation

National average

CA

PA

CIT

Y T

O A

CT






73% Medium 58.2%


58% -92% Medium 35.2%


0% Weak 29.8%


14% Weak 33.5%


8% Weak 25.8%


24% Weak 52.7%







84% Strong 66.8%


40% Weak 61.9%


4% Weak 3.4%

111


11. Regional profile: Oshana Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT



100% Strong 100%


80% Strong 48.8%


0% Weak 45.2%



70% Medium 45.3%


80% Strong 70.6%


24% Weak 13.8


46% Weak 46 %







20% Weak 24.8%



112


Regional situation

National average

CA

PA

CIT

Y T

O A

CT


Community 76.5% Strong 50.3%



Health workers have correct knowledge on nutrition protocols 45% Weak 58.2%

Health workers have skills to implement nutrition counselling 42-58% Weak 35.2%


33% Weak 29.8%


33% Weak 33.5%


69% Medium 25.8%


90% Strong 52.7%






Provision of essential supplies and equipment at health facilities 66% Medium 66.8%


88% Strong 61.9%


0% Weak 3.4%

113


12. Regional profile: Oshikoto Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT



100% Strong 100%


24% Weak 48.8%


78% Strong 45.2%



70% Medium 45.3%


85% Strong 70.6%


24% Weak 13.8


100% Strong 46 %







24% Weak 24.8%



114


Regional situation

National average

CA

PA

CIT

Y T

O A

CT






59% Medium 58.2%


25% Weak 35.2%


0% Weak 29.8%


67% Medium 33.5%


17% Weak 25.8%


0% Weak 52.7%







57% Medium 66.8%


40% Medium 61.9%


4% Weak 3.4%

115


13. Regional profile: Otjozondjupa Region




Regional situation

National average

CA

PA

CIT

Y T

O A

CT



100% Strong 100%


80% Strong 48.8%


33% Weak 45.2%



20% Weak 45.3%


72% Medium 70.6%


24% Weak 13.8 %


25% Weak 46 %




Summaries of nutrition data made available to regions 87% Strong 29.8%



22% Weak 24.8%



116


Regional situation

National average

CA

PA

CIT

Y T

O A

CT






55% Medium 58.2%


42-58% Medium 35.2%


50% Medium 29.8%


0% Weak 33.5%


33% Weak 25.8%


100% Strong 52.7%







54% Strong 66.8%


50% Medium 61.9%


0% Weak 3.4%

117


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123


ANNEX I: NUTRITION LANDSCAPE ANALYSIS SURVEY TEAM

Name AGENCY

Marjorie Van Wyk Ministry of Health and Social Services

Marius Shoombe Ministry of Defence

Fred Alumasa FANTA-3

Emilia Haimbili Ministry of Gender Equality and Child Welfare

Victoria Hango Ministry of Information and Communication Technology

Florence Soroses Ministry of Health and Social Services

Taimi Nauiseb University of Namibia

Sophia Nicodemus Ministry of Health and Social Services

Catherine Tiongco UN World Food Programme

Nicole Angermund Ministry of Health and Social Services

Hilde Nashandi Ministry of Health and Social Services

Dr Andemichael Ghirmay World Health Organization

Rachael Mhango International Technical and Educational Center for Health

Agnes Mukobonda Ministry of Education

Alfeus Shidole Ministry of Defence

Marijke Rittmann Ministry of Health and Social Services

Kaia Engesveen World Health Organization, Geneva


124

ANNEX II: LIST OF INDIVIDUALS/ORGANISATIONS THAT

PARTICIPATED IN THE PROCESS OF NUTRITION LANDSCAPE ANALYSIS FOR NAMIBIA

Office of the Prime Minister, Directorate of Disaster Risk Management (OPM/DDRM)

Ministry of Health and Social Services (MoHSS)

Ministry of Gender Equality and Child Welfare (MoGECW)

Ministry of Education (MoE)

Ministry of Information and Communication Technology (MICT)

Ministry of Defence (MoD)

Ministry of Agriculture, Water and Forestry (MAWF)

Regional councillors from Erongo, Kunene, Ohangwena, Oshikoto and Otjozondjupa

regions

World Health Organization (WHO)

UN World Food Programme (WFP)

United Nations Children’s Fund (UNICEF)

United States Agency for International Development (USAID)

Centers for Disease Control (CDC)

International Technical and Educational Center for Health (I-TECH)

Food and Nutrition Technical Assistance (FANTA) Project

University of Namibia (UNAM)

Polytechnic of Namibia

National Health Training Center (NHTC)

Namibian Red Cross Society (NRCS)

Catholic AIDS Action (CAA)

Synergos

Global Alliance for Improved Nutrition (GAIN)

125


ANNEX III : NUTRITION LANDSCAPE ANALYSIS SURVEY

QUESTIONNAIRES


126

ANNEX III : NUTRITION LANDSCAPE ANALYSIS SURVEY

QUESTIONNAIRES

Form 1. National-level stakeholders

Semi-structured interview for government agencies and

other stakeholders (e.g. UN agencies, donors, NGOs) at

national level

ID:___

Completed by:

The following is possible introductory information you may wish to provide before starting the

interview:

"In order to reinforce nutrition actions, the Office of the Prime Minister/ Nutrition Alliance for

Improved Nutrition/ Ministry of Health and Social Services and its partners have decided to

undertake a Landscape Analysis Country Assessment to assess the readiness to scale-up

nutrition actions in the country. The readiness framework provided by the Landscape

Analysis investigates commitment and capacity of nutrition stakeholders and service

providers in a country. In this respect we are seeking to get your views on current nutrition

challenges and how your agency or organisation responds to these.

The country assessment team consists of members from WHO, WFP, MHSS, OPM, NAFIN,

Synergos, USAID, CDC and line ministries. We have split into 4 teams and are interviewing

stakeholders at the national, provincial/regional, district, and facility level in 4 field locations.

This interview is not a test of your knowledge, but a tool to learn more about your agency's

or organisation's current activities which relate to nutrition. In particular, we would like to

profit from the knowledge and experience that you have through working in nutrition in the

country. Your answers will be treated with confidentiality. The interview will take

approximately 45-60 minutes.

The results of the country assessment will be analysed by the assessment team and will be

shared and presented at a consensus meeting on a future date. We hope that you have

received the invitation to the planned consensus meeting and that you will be able to join the

discussions at the meeting and help refine recommendations and next steps." (If not, inform

the respondent of the plan for the meeting.)

Name of the Agency/Organisation/Department/Unit:

Date of visit

d d m m y y y y

Respondents:

Name:

Position:

Background:

Name:

Position:

Background:

Name:

Position:

Background:

Section 1. Nutrition situation and priorities

1.1 What do you perceive as the major nutrition problems in your country and what are the most

important causes of these problems? If the respondent only mentions underlying causes (e.g. poverty, lack of education, etc), try to obtain information on

how the respondent sees those underlying causes affect the nutrition status of people (e.g. how does poverty affect nutrition among children).

Problems mentioned:

Tick the appropriate box (es) and take brief notes of any further description. But DO NOT READ OUT THE OPTIONS. Try to obtain the views of the respondents in their words.

Undernutrition: Underweight:

Stunting:

Wasting:

Overweight and obesity:

Vitamin or mineral deficiencies, specify which ones:

Other:

Causes of existing nutrition problems mentioned:

Tick the appropriate box (es) and take brief notes of any further description. Again DO NOT READ OUT THE OPTIONS. Try to obtain the views of the respondents in their words.

Food insecurity: Poor dietary quality:

Poor dietary quantity:

Increasing food prices:

Insufficient health services/Unhealthy environment:

Inadequate caring practices of infants and young children:

Lack of knowledge:

Poverty:

Natural disasters:

Other:

Section 2. Nutrition policies and activities

2.1 Do you know of any key nutrition policies, strategies and actions in the country?

Yes No Don't know

If no, skip to question 2.4.

2.1.1 What are the key policies, strategies and action plans of importance to nutrition in the country? If any policy documents not included in the desk review are mentioned, ask to receive a copy.

1.

2.

3.

4.

5.

2.2 Do you feel these identified policies, strategies and action plans adequately address the

nutrition problems and causes that you mentioned earlier?

Yes No Don't know

If no, what is missing?

2.3 Does your agency use or contribute to the implementation of these policies, strategies and

action plans?

Yes No Don't know

If yes, how does your agency use or contribute to the implementation of these policies, strategies and action plans? Please give specific examples

2.4 What are the specific nutrition programmes and interventions implemented by your agency?

Review the information regarding intervention programmes provided in the stakeholder mapping tool used as part of the Desk Review and complete any missing information you are able to collect through this interview. If the information has not been completed during the Desk Review, fill in the table overleaf now.

If programme documents are available, ask to receive a copy, if possible.

Please indicate and describe major nutrition intervention programmes being implemented

Please use these answering options: Area: urban, rural, peri-urban; Status: ongoing, completed, planned; Target group: children 0-23 mos, children 6-23 mos, children 6-59 mos,

school-aged children 5-9 yrs, adolescents 10-19 yrs, women of reproductive age, pregnant women, lactating women, pregnant & lactating women, adolescent girls, all women, households,

men, fathers, entire population, households in food insecurity, elderly or other; Delivery channel: community-based (extension workers), hospital, health center, primary health

care/dispensary, kindergarten/school, commercial/private sector, tv, radio, mass campaign, NGOs or other

Programme information

Title:

Specific interventions

implemented in programme

List up to 10 interventions

Target

group

Select

Budget and

funding secured Delivery

channel

Select

Coverage

Number of

beneficiaries

M&E system

Who is

responsible for

M&E

M&E

indicators

Indicators used

in M&E

Comments

Please note

additional comments

Region

Amount

budgeted

Amount

secured

District:

1.

Area

2.

Status

3.

Start date

4.

End date

5.

Implementing

Partners:

6.

7.

Budget

8.

Funding secured*

9.

Funding source

10.

*Amount or %

2.5 Do you know about the International Code of Marketing of Breast-milk Substitutes?

Yes No Don’t know

If yes, in what ways does the agency/department/unit enforce the International Code

of Marketing of Breast-milk Substitutes?

2.6 Does your agency/department/unit take any actions to mitigate the effects of the food price rises?

Yes No Don’t know

If yes, please describe the action taken by your agency/department/unit to mitigate

food prices

Section 3. Budget and funding

3.1 What is the annual budget of your agency that is dedicated to nutrition-related

activities? Approximately what percentage does this represent of the total budget of your agency?

Annual budget for nutrition-related

activities Approximate % of total

budget

Current year: N$

Last year: N$

3.2 Funding source

3.2.1 If implementing agency:

What are the sources of funding for nutrition activities implemented by your agency? How large part of the nutrition budget within your agency does each one represent?

Main donors to nutrition budget % of nutrition budget

1.

2.

3.

4.

5.

3.2.2 If donor agency:

Who are the main recipients of your funds and what kind of nutrition programmes or projects and activities do you support?

Main recipients of funds for nutrition Types of activities funded

1.

2.

3.

4.

5.

3.3 Do you feel there is adequate funding available to tackle the nutrition challenges being faced in the country?

Yes No Don't know

Describe:

3.3.1 If no, do you have any specific plans or ideas to increase funding for nutrition

in your agency?

Section 4. Nutrition coordination system

4.1 Are there any coordination mechanisms (committees, task force, interagency working

groups, etc.) that address nutrition at the national level?

Yes No Don't know

If respondent answers "no" or "don't know", please proceed to question 4.4

4.2 If yes, which coordination mechanisms (committees, task force, interagency working groups, etc.) that address nutrition does your agency participate in? How often do you or a representative of your agency attend the meetings of the coordination mechanism?

If no specific information is available, describe if agency participates in all meetings, most meetings, seldom or never.

Coordination mechanism Attendance to meetings

1.

2.

3.

4.

5.

4.2.1 If your agency never or seldom participate in any of the existing nutrition coordination mechanisms, why not?

Describe:

4.3 What do you perceive as the major strengths of the current system for coordinating nutrition actions in the country? List according to importance.

1.

2.

3.

4.4 What do you perceive as the major problems or challenges of the coordination of nutrition actions that should be improved? List according to importance.

1.

2.

3.

4.5 How do you coordinate activities at sub-national levels, if your agency also operates at sub-national levels?

4.5.1 How often do you meet with district level coordinators, if existing?

4.5.2 Do you have a list of district coordinators? Ask to receive a copy, if possible.

Yes Yes and can show a copy

No Don’t know

4.6 If you are working with partners to implement nutrition programmes, could you think of

one successful partnership? Please describe the reasons to why this has been successful.

Section 5. Human resources for nutrition

5.1 Does your agency have staff dedicated full-time or part-time to manage or implement

nutrition programmes and activities?

Yes No Don't know

5.1.1 If yes, how many staff work full-time or part-time on nutrition at different levels

(national/central, provincial/regional, district and community) and how many of them have higher degrees or other training in nutrition?

Level

Total number of

staff


Number of staff with training

Full-time Part-time Degree in nutrition

Other training

National/Central

Provincial

District

Community

5.1.2 If staff members have participated in nutrition training, what were the topics of these trainings, who organised them and when?

Topics of training Who organized the training? When was it organized?

5.1.3 If no staff have participated in training during the last two years, why not?

Describe:

5.2 Do you think that there are enough nutritionists or staff with higher training in nutrition at the different levels (national, provincial, regional, district, community) in the country?

Describe:

5.3 What do you think should be done to strengthen nutrition capacities in the country?

5.4 Do you think the nutrition services need to be expanded?

Yes No Don't know

5.4.1 If nutrition services were to be scaled up and expanded in the country, what do you think needs to be done? What kind of capacities would be required? How could those capacities be built?

Describe:

5.5 Does your agency offer any training in nutrition?

Yes No Don't know

5.5.1 If yes, please indicate the topic, duration, participants and training material

related to these trainings.

Training topic Duration

of the training

Who participates in the training?

Training material used (Title, language, year of

publication)

5.5.2 Have staff from other agencies been invited to take part in trainings your

agency offers?

Yes No Don't know

Describe:

5.5.3 Do these trainings include any follow-up training or post-training supervision?

Describe:

5.5.4 How do you monitor or evaluate the effectiveness of these trainings?

Describe:

Section 6. Nutrition information system

6.1 Does your agency/department/unit use nutrition information/data?

Yes No Don't know

If no skip to Section 7, Advocacy and Scaling Up

6.2 What types of information/data on nutrition does your agency collect? Please describe nutrition indicators collected, target population groups surveyed and how often data are collected.

Nutrition indicators

collected

Target population group How often do you collect the

data?

6.2.1 How is this information/data collected and collated? Probe: surveys, routine,

data, etc.

6.2.2 If your agency/department/unit is collecting or collating data, how do you share these results with Regional and district levels and with other stakeholders?

6.3 How does your agency use these collected data or any other available nutrition data?

6.3.1 If your agency uses other available nutrition data, what are they and how do

you obtain them?

Type of data Manually collected data Electronically collected data

Surveys

Routine Data

Other (please specify)

Section 7. Advocacy and scaling up

7.1 Is your agency/department/unit doing anything to promote/protect breastfeeding?

Yes No Don't know

7.2 What do you perceive as the major barriers and challenges for scaling-up nutrition actions in the country? How could your agency contribute to overcoming these barriers? Please specify any concrete action or input that you could provide.

Barriers and challenges to

scaling up nutrition action

What your agency could do to overcome those

barriers and challenges

7.3 How can a multi-sectoral collaboration be encouraged/strengthened among stakeholders to scale-up nutrition actions? Can you give any examples that you have used which has resulted in improved cooperation or increased commitment to nutrition from stakeholders in the country? Please describe and give examples.

7.4 Does your agency/department/unit use any of the following documents to advocate

nutrition?

Yes No If yes, please describe how it was done:

Vision 2030

MDG

NDP 3

Namibia Nutrition Profile

Convention of the Right of the Child

ILO

IYCF

Other

7.5 With the current level of resources, what kind of support (i.e. money, capacity building, in-kind, supplies, etc.) could your agency provide to support scaling-up of nutrition actions?

1.

2.

3.

Section 8. Concluding questions

8.1 In your opinion, what is the top priority of this country in order to accelerate reduction of

malnutrition?

8.2 Is there anything else that you would like to tell us to have a better understanding about

the nutrition situation in the country or issues that you feel are important that we have not touched upon during the interview?

At the end of the interview:

Thank the interviewee for taking time to share so much valuable information

Ask if he/she has any questions to ask you

Remind him/her about the consensus meeting being planned and that you look forward to seeing him/her there.

Form 2. Regional-level stakeholders

Semi-structured interview for government agencies and

other stakeholders (e.g. UN agencies, donors, NGOs) at

regional level

ID:___

Completed by:

The following is possible introductory information you may wish to provide before

starting the interview:

"In order to reinforce nutrition actions, the Office of the Prime Minister/ Nutrition

Alliance for Improved Nutrition/ Ministry of Health and Social Services and its

partners have decided to undertake a Landscape Analysis Country Assessment to

assess the readiness to scale-up nutrition actions in the country. The readiness

framework provided by the Landscape Analysis investigates commitment and

capacity of nutrition stakeholders and service providers in a country. In this respect

we are seeking to get your views on current nutrition challenges and how your

agency or organisation responds to these.

The country assessment team consists of members from WHO, WFP, MHSS, OPM,

NAFIN, Synergos, USAID, CDC and line ministries. We have split into 4 teams and

are interviewing stakeholders at the national, regional, district and facility level in 4

field locations.

This interview is not a test of your knowledge, but a tool to learn more about your

agency's or organisation's current activities which relate to nutrition. In particular, we

would like to profit from the knowledge and experience that you have through

working in nutrition in the region. Your answers will be treated with confidentiality.

The interview will take approximately 45-60 minutes.

The results of the country assessment will be analysed by the assessment team and

will be shared and presented at a consensus meeting on a future date. We hope that

you have received the invitation to the planned consensus meeting and that you will

be able to join the discussions at the meeting and help refine recommendations and

next steps." (If not, inform the respondent of the plan for the meeting.)

Name of the Agency/Organisation/Department/Unit:

Date of visit

d d m m y y y y

Respondents:

Name:

Position:

Background:

Name:

Position:

Background:

Name:

Position:

Background:


1.1 What do you perceive as the major nutrition problems in your region and what are the

most important causes of these problems? If the respondent only mentions underlying causes (e.g. poverty, lack of education, etc), try to obtain

information on how the respondent sees those underlying causes affect the nutrition status of people (e.g. how does poverty affect nutrition among children).

Problems mentioned:

Tick the appropriate box (es) and take brief notes of any further description. But DO NOT READ

OUT THE OPTIONS. Try to obtain the views of the respondents in their words.


Stunting:

Wasting:



Other:


Tick the appropriate box(es) and take brief notes of any further description. Again DO NOT READ OUT THE OPTIONS. Try to obtain the views of the respondents in their words.






Lack of knowledge:

Poverty:

Natural disasters:

Other:

Section 2. Nutrition policies and activities

2.1 Do you know of any key nutrition policies, strategies and actions in the country?

Yes No Don't know

If no, skip to question 2.4.

2.1.1 What are the key policies, strategies and action plans of importance to

nutrition in the country?

1.

2.

3.

4.

5.

2.2 Do you feel these identified policies, strategies and action plans adequately address

the nutrition problems and causes that you mentioned earlier?

Yes No Don't know


2.3 Does your agency use or contribute to the implementation of these policies, strategies

and action plans?

Yes No Don't know

If yes, how does your agency use or contribute to the implementation of these policies, strategies and action plans? Please give specific examples

2.4 What are the specific nutrition programmes and interventions implemented by your

agency?

Please include information regarding programmes and the specific interventions included in these programmes using the table overleaf.

Please note that some indicators (i.e. area and status of programme, target group and delivery channel of interventions) should be answered using the predefined answering options listed above the table.








Title:




Target

group

Select

Budget and


channel

Select

Coverage

Number of

beneficiaries

M&E system

Who is

responsible for

M&E

M&E

indicators

Indicators used

in M&E

Comments

Please note

additional comments

Region

Amount

budgeted

Amount

secured

District:

1.

Area

2.

Status

3.

Start date

4.

End date

5.

Implementing

Partners:

6.

7.

Budget

8.

Funding secured*

9.

Funding source

10.

*Amount or %

Section 3. Regional budget and funding

3.1 What is the annual budget of your agency that is dedicated to nutrition-related activities?

Approximately what percentage does this represent of the total budget of your agency?

Annual budget for nutrition-related

activities Approximate % of total

budget

Current year:

Last year:

3.2 What are the regular sources of funding (National and International) for nutrition activities

implemented by your agency/department/unit and how large part of the nutrition budget does each one represent? What ad hoc sources of funding does your agency/department/unit receive?

Regular Funding Sources

% of nutrition budget

Ad hoc Sources of Funding

% of nutrition budget

1

% 1

%

2

% 2

%

3

% 3

%

4

% 4

%

3.3 Do you feel there is adequate funding available to tackle the nutrition challenges being

faced in the region?

Yes No Don't know

Describe:

3.3.1 If no, do you have any specific plans or ideas to increase funding for nutrition in

your agency?

Section 4. Nutrition coordination system

4.1 Are there any coordination mechanisms (committees, task force, interagency working

groups, etc.) that address nutrition at the regional level?

Yes No Don't know

If respondent answers "no" or "don't know", please proceed to question 4.4

4.2 If yes, which coordination mechanisms (committees, task force, interagency working groups, etc.) that address nutrition does your agency participate in? How often do you or a representative of your agency attend the meetings of the coordination mechanism?

If no specific information is available, describe if agency participates in all meetings, most meetings, seldom or never.

Coordination mechanism Attendance to meetings

1.

2.

3.

4.

5.

4.2.1 If your agency never or seldom participate in any of the existing nutrition coordination mechanisms, why not?

Describe:

4.3 What do you perceive as the major strengths of the current system for coordinating nutrition actions in the province? List according to importance.

1.

2.

3.

4.4 What do you perceive as the major problems or challenges of the coordination of nutrition actions that should be improved? List according to importance.

1.

2.

3.

4.5 How do you coordinate activities at district and community levels?

4.5.1 How often do you meet with district level coordinators, if existing?

4.5.2 Do you have a list of district coordinators? Ask to receive a copy, if possible.

Yes Yes and can show a copy

No Don’t know

4.6 If you are working with partners to implement nutrition programmes, could you think of one

successful partnership? Please describe the reasons to why this has been successful.

Section 5. Human resources for nutrition

5.1 Does your agency have staff dedicated full-time or part-time to manage or implement nutrition

programmes and activities?

Yes No Don't know

If no, 5.1.1 Who is responsible for nutrition in your region?

Code

If yes

5.1.2 How many staff work full-time or part-time on nutrition at different levels (regional, district and community) and how many of them have higher degrees or other training in nutrition?

Level

Total number of

staff


Number of staff with training

Full-time Part-time Degree in nutrition

Other training

regional

District

Community

5.1.3 If staff members have participated in nutrition training, what were the topics of these trainings, who organized them and when?

Topics of training Who organised the training? When was it organised?

5.1.4 If no staff have participated in training during the last two years, why not?

Describe:

5.2 Do you think that there are enough nutritionists or staff with higher training in nutrition at the different levels (regional, district, community) in the region?

Describe:

5.3 What do you think should be done to strengthen nutrition capacities in the region?

5.4 If nutrition services were to be scaled up and expanded in the region, what do you think needs to be done? What kind of capacities would be required? How could those capacities be built?

Describe:

5.5 Does your agency offer any training in nutrition?

Yes No Don't know

5.5.1 If yes, please indicate the topic, duration, participants and training material used

related to these trainings.

Training topic Duration

of the training


Training material used (Title, language, year of

publication)

5.5.2 Have staff from other agencies been invited to take part in trainings your agency

offers?

Yes No Don't know

Describe:


Pre- test Post – test Site visits Other

Describe:


Describe:

Section 6. Nutrition information system

6.1 Does your agency/department/unit use nutrition information/data?

Yes No Don't know

If no skip to Section 7, Advocacy and Scaling Up

6.2 What types of information/data on nutrition does your agency collect? Please describe nutrition indicators collected, target population groups surveyed and how often data are collected.

Nutrition indicators

collected


data?

6.2.1 How is this information/data collected and collated? Probe: surveys, routine, data,

etc.

6.2.2 If your agency/department/unit is collecting or collating data, how do you share these results with Regional and district levels and with other stakeholders?

6.3 How does your agency use these collected data or any other available nutrition data?

6.3.1 If your agency uses other available nutrition data, what are they and how do you

obtain them?


Surveys

Routine Data


Section 7. Advocacy and scaling up

7.1 Is your agency/department/unit doing anything to promote/protect breastfeeding?

Yes No Don't know

7.2 What do you perceive as the major barriers and challenges for scaling-up nutrition actions in the region? How could your agency contribute to overcoming these barriers? Please specify any concrete action or input that you could provide.


scaling up nutrition action

What your agency could do to overcome those

barriers and challenges

7.3 How can a multi-sectoral collaboration be encouraged/strengthened among stakeholders to scale-up nutrition actions? Can you give any examples that you have used which has resulted in improved cooperation or increased commitment to nutrition from stakeholders in the country? Please describe and give examples.

7.4 Does your agency/department/unit use any of the following documents to advocate

nutrition?

Yes No If yes, please describe how it was done:

Vision 2030

MDG

NDP 3

Namibia Nutrition Profile

Convention of the Right of the Child

ILO

IYCF

Other

7.5 With the current level of resources, what kind of support (i.e. money, capacity building, in-kind, supplies, etc.) could your agency provide to support scaling-up of nutrition actions?

1.

2.

3.


8.1 In your opinion, what is the top priority of this region in order to accelerate reduction of

malnutrition?

8.2 Is there anything else that you would like to tell us to have a better understanding about the

nutrition situation in the province or issues that you feel are important that we have not touched upon during the interview?

At the end of the interview:



Form 3. District-level management staff

Semi-structured interview

ID:___

Completed by:

The following is possible introductory information you may wish to provide before starting

the interview:

"In order to reinforce nutrition actions, the Office of the Prime Minister/ Nutrition Alliance

for Improved Nutrition/ Ministry of Health and Social Services and its partners have

decided to undertake a Landscape Analysis Country Assessment to assess the

readiness to scale-up nutrition actions in the country. The readiness framework provided

by the Landscape Analysis investigates commitment and capacity of nutrition

stakeholders and service providers in a country. In this respect we are seeking to get

your views on current nutrition challenges and how your department/district responds to

these.


NAFIN, Synergos, USAID, CDC and line ministries. We have split into 4 teams and are

interviewing stakeholders at the national, provincial/regional, district, and facility level in

4 field locations.


department/district's current activities which relate to nutrition. In particular, we would like

to profit from the knowledge and experience that you have through working in nutrition in

the district. Your answers will be treated with confidentiality. The interview will take


The results of the country assessment will be analysed by the assessment team and will

be shared and presented at a consensus meeting on a future date. We are confident

that your invaluable inputs will enrich the analysis and contribute to the formulation of

relevant recommendations."

Date of visit

d d M m y y y y

Province/region:

District:

Department:

Respondent:

Name:

Position:

Background:


1.1 What do you perceive as the major nutrition problems in the districts and what are the most

important causes of these problems? If the respondent only mentions underlying causes (e.g. poverty, lack of education, etc), try to obtain information

on how the respondent sees those underlying causes affect the nutrition status of people (e.g. how does poverty affect nutrition among children).

Problems mentioned:

Tick the appropriate box(es) and take brief notes of any further description. But DO NOT READ OUT THE OPTIONS. Try to obtain the views of the respondents in their words.


Stunting:

Wasting:



Other:


Tick the appropriate box(es) and take brief notes of any further description. Again DO NOT READ

OUT THE OPTIONS. Try to obtain the views of the respondents in their words.






Lack of knowledge:

Poverty:

Natural disasters:

Other:

Section 2. Nutrition programme and activities

2.1 What are the main district plans relevant to nutrition?

Probe for district development plans or sectoral plans in health, agriculture or other relevant sectors, as well as large scale health programmes such as MCH or IMCI. Ask to receive a copy.

2.2 Do you feel these plans adequately address the main nutrition problems and their causes that you mentioned earlier?

Yes No Don't know


2.3 Do the district plans include operational plans with budget where nutrition is included?

If operational plans and budget are separate from the plans received, ask to receive a copy of these too.

Yes No Don't know

2.4 Which nutrition programmes and activities are included in these district plans?

Describe the target groups of these programmes and activities, the delivery channels (e.g. clinic- or community-based) and indicate whether they currently are being implemented.

Nutrition programme/activities in district

plan

Target

group

Delivery

channel

Currently

being

implemented?

2.4.1 Are there other nutrition-related programmes and activities implemented that are not included in the district plan?

2.5 What activities are implemented at community level in your district to promote

2.5.1 Maternal and Child Health (MCH):

Maternal nutrition

Adolescent Friendly Health Services

Family Planning

Growth monitoring Programme o Stunting Reduction o Identification and treatment of moderate to severe malnutrition

Micronutrient Deficiency Prevention

Deworming

Prevention of Diarrhoea

Treatment of Diarrhoea with Zinc supplementation and Oral Rehydrate Solution

Provision of Insecticide Treated Bed Nets 2.5.2 Infant and Young Child Feeding (IYCF):

Breastfeeding

Complementary Feeding

PMTCT 2.5.3 Education:

School Health Programmes

Early Childhood Development

2.5.4 Food Security/ Livelihoods/ Incoming Generating

Food diversification o Use of Animal Food Sources o Vegetable gardens

Aquaculture

Small Scale Farming

Conservancy

Food for work programme

2.5.5 Healthy Eating and Physical Activity to Prevent Overweight:

2.5.6 Identification and management of severe or moderate malnutrition:

2.5.7 Water, Hygiene and Sanitation:

Handwashing

Pest Prevention

Environmental Sanitation

2.5.8 Community Based Programmes with Nutrition Objectives (e.g. Soup Kitchens_

2.5.9 Healthy eating and physical activity to prevent overweight:

2.5.10 Any other community-based programmes with nutrition objectives:

2.6 Are nutrition messages communicated to the communities?

2.6.1 If yes, please describe

2.6.2 If no, please give possible barriers/obstacles to the communication of nutrition

messages in the community

2.7 Do you know about the International Code of Marketing of Breast-milk Substitutes?

Yes No Don’t know

If yes, in what ways does the agency/department/unit enforce the International Code of

Marketing of Breast-milk Substitutes?

2.8 Does the district have any mechanisms in place to support pregnant and lactating mothers in order to promote and prolong breastfeeding?

Yes No Don’t know

If yes, please describe the methods used to support pregnant and lactating mothers in your district.

2.9 Do you know about the Baby-friendly Hospital Initiative?

Yes No Don’t know

2.9.1 If yes, how many facilities are there in the district, how many of them are certified BFHI (Baby-friendly Hospital Initiative) and how many of them have been re-assessed within the past 3 years?

Total number of facilities:

Number of BFHI certified facilities:

Number of BFHI certified facilities that have been re-assessed within the past 3 years:

Number of facilities preparing to become certified BFHI

2.10 Are you satisfied with the district nutrition programmes and activities? What are the success areas and what are the areas to improve?

Success areas:

Areas to improve:

2.11 What do you perceive as the major barriers and challenges for scaling-up nutrition or nutrition-related actions in the district? How could your district/department contribute to overcoming these barriers? Please specify any concrete action or input that you could provide within the current level of human and financial resources


scaling up nutrition or nutrition-

related action

What your district/department could do to

overcome those barriers and challenges

Section 3. Budget

3.1 Do you feel there is adequate funding to tackle the nutrition situation in the district?

Yes No Don't know

3.1.1 If no, do you have any specific plans or ideas to increase funding?

3.2 Is there a separate budget line for nutrition within the district budget?

Yes No Don't know

If yes:

3.2.1 Which activities are included in the nutrition budget line? What is the amount budgeted, how much of the budgeted amount has been secured and what are the funding sources?

Nutrition activities

included in the budget

Amount

budgeted

% of

funding

secured

Funding sources

%

%

%

%

%

If no:

3.2.2 How are nutrition activities that are implemented in the district funded?

3.3 With the available resources in your district, what are your specific suggestions as to how

you could improve nutrition activities in the district?

Section 4. Responsibilities and coordination

4.1 Within the district team, who has the main responsibility for nutrition?

Primary Health Care Supervisor

Registered Nurse/ Enrolled Nurse

Maternal-Child Health programme officer

Health Worker

Community Counsellors

Volunteers

Other (Please Specify):______________________

4.2 What nutrition training does this person have?

4.3 What other, if any, non-nutrition related responsibilities does this person have?

Ask to receive a copy of the job description, if possible.

4.4 Within the government and among partners, who are the other players working in nutrition in your district? Please specify what nutrition activities they undertake or contribute to.

Organisation Nutrition activity

4.4.1 Can you describe some examples of successful partnerships in nutrition in the district and indicate the reasons why these partnerships are successful?

4.4.2 What are your suggestions to how partners could work better together to improve nutrition?

4.5 How are nutrition activities coordinated in the district? What are the institutional arrangements/platforms?

4.5.1 Who is responsible for co-ordination of nutrition activities?

Person Responsible Nutrition Activity

If coordination mechanism (e.g. working group, task force, committee, etc.) exists:

4.5.2 Who participate?

4.5.3 How often do they meet?

Frequency of meetings:

Number of meetings in the past 6 months:

4.5.4 Can you give some examples of decisions made by the working group/ coordination mechanism that have been implemented?

4.6 What could be your district’s specific contributions in order to make partners work better together for nutrition?

Section 5. Training

5.1 Do you have a district training plan for nutrition? If yes, ask to receive a copy.

Yes No Don't know

5.2 What nutrition-related training has there been in your district in the past year?

Ask to see copy of any training material, note scope, date and language, if possible.

Trainings Participants Materials used

5.3 What other training has the staff in this district attended at national, regional and international level?

5.4 Do any of these trainings include any follow-up training or post-training supervision?

Yes No Don't know

If yes, describe:

National:

Regional:

International:

Section 6. Supervision and support

6.1 How often does the person in charge of nutrition get to visit facilities and/or communities to supervise or to provide nutrition programme support?

Everyday Every week Every month Less often

6.1.1 What supervisory manuals are used? Ask to see a copy and note title and data

6.2 How often and what kind of support has your district received from the national or provincial/regional levels during the last two years regarding nutrition programming, planning and implementation? Probe for training, budget support, research, dialogue, field visits.

Support Given

Nutrition Training

Budget support

Research

Dialogue

Field visits

Other (please

specify)

6.3 Are you satisfied with the support received from the national or provincial/regional levels?

What are your specific suggestions to improve?

Section 7. Information management systems

7.1 What are the most important nutrition indicators that are routinely collected and/or collated at district level? How often are data collected? Ask to see copy of reports of routine data relevant for nutrition and note whether they are complete and accurate

Nutrition indicators Frequency of data

collection

Do data seem to be

complete and accurate?

7.1.1 How is this information/data collected and collated? Probe: surveys, routine, data,

etc.

7.2 How do you use this information?


Surveys

Routine Data


7.3 Where do you send the nutrition data collected or collated?

7.3.1 Have you ever received feedback on the information on nutrition that you send to the provincial/regional or national level?

Yes No Don’t know

7.3.2 If yes, is this feedback useful? And how do you use this feedback?

7.3.3 If no, please give possible reasons as to why not?

7.4 What nutrition information do you receive from national and provincial/regional level and how often do you receive such information? Probe for data summaries, reports or analyses.

Summaries Regional National Frequency

Reports

Data

Analyses


8.1 In your opinion, what are the top priorities of your district in order to accelerate reduction of malnutrition?

8.2 Is there anything else that you think you should tell us to have a better understanding about

nutrition situation in the district?



Form 4. Facility manager and staff responsible for

nutrition (including facility checklist)

Semi-Structured Group* Interview

ID:___

Completed by:

The following is possible introductory information you may wish to provide before starting

the interview :

"In order to reinforce nutrition actions, the Office of the Prime Minister/ Nutrition Alliance

for Improved Nutrition/ Ministry of Health and Social Services and its partners have

decided to undertake a Landscape Analysis Country Assessment to assess the

readiness to scale-up nutrition actions in the country. The readiness framework provided

by the Landscape Analysis investigates commitment and capacity of nutrition

stakeholders and service providers in a country. In this respect we are seeking to get

your views on current nutrition challenges and how your facility responds to these.


NAFIN, Synergos, USAID, CDC and line ministries. We have split into 4 teams and are

interviewing stakeholders at the national, provincial/regional, district, and facility level in

4 field locations.


facility's current activities which relate to nutrition. In particular, we would like to profit

from the knowledge and experience that you have through working in nutrition in the

area. Your answers will be treated with confidentiality. The interview will take

approximately 60 minutes.

The results of the country assessment will be analysed by the assessment team and will

be shared and presented at a consensus meeting on a future date. We are confident

that your invaluable inputs will enrich the analysis and contribute to the formulation of

relevant recommendations."

* It is desirable to have both the Facility Manager and the person responsible for the nutrition programme together for this

group interview. Where this is not possible, please conduct two interviews in order to capture both viewpoints.

Date of visit

d d m m y y y y

Region: District:

Facility: Unit:

Intermediate/ Intermediate Refferal

Hospital

District Hospital

Referral Hospital

Clinic

Health Centre

Maternity/Birthing Unit

Other: _________________________ ___

Out-Patient Department Maternity/Birthing Unit Children’s (pediatric) ward Other: ______________________ ______

Respondents:

Name:

Position:

Background:

Name:

Position:

Background:


1.1 What do you perceive as the major nutrition problems in your country and what are the

most important causes of these problems? If the respondent only mentions underlying causes (e.g. poverty, lack of education, etc), try to obtain information

on how the respondent sees those underlying causes affect the nutrition status of people (e.g. how does poverty affect nutrition among children).

Problems mentioned:



Stunting:

Wasting:



Other:








Lack of knowledge:

Poverty:

Natural disasters:

Other:

1.2 What are the most common nutrition-related cases reported for referral to your facility?

2.1 Does your facility provide any of the following interventions to promote nutrition?

Please complete the table overleaf.

If yes to a specific intervention, ask about the target group(s) and other relevant details. Do

not read out the options provided in the table, but rather ask open-ended questions that will

answer each of them, e.g. "Are all children getting vitamin A supplementation, if not what

are the criteria for a child to receive vitamin A supplementation?", "What is the frequency of

intake of iron and folic acid supplementation?".

Please also check the availability of related supplies and materials (if more feasible, this

can be done immediately after completion of the questionnaire).

2.2 Is your facility designated BFHI (Baby-friendly Hospital Initiative)? If yes, when was it designated first time and when was date of last re-designation?

Yes No Don't know

If yes, date of first designation:

If yes, date of last re-designation:

2.3 How is nutrition integrated into other primary health care programmes or activities?

Probe: How nutrition is integrated into Integrated Management of Neonatal Childhood Illness (IMNCI), maternal health, adolescent health, HIV/AIDS,, etc.

Programme How is nutrition integrated?

IMNCI

Maternal and Child Health

Adolescents Health

HIV/AIDS


Section 2. Nutrition activities and integration into other

programmes

Do not read out the options provided in the table, but rather ask open-ended questions that will answer each of them, e.g. "Are all children getting

vitamin A supplementation, if not what are the criteria for a child to receive vitamin A supplementation?", "What is the frequency of intake of iron

and folic acid supplementation?".

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?

Further details specific to interventions

What kind of advice and/or treatment is provided?

Checklist for related supplies and materials

Are the following supplies and material available?

Counselling and

support for

appropriate

breastfeeding

Yes No

All mothers

Other:_______

What are you advising?

Early initiation of breastfeeding within 1 hour

Exclusive breastfeeding up to 6 months

Continued breastfeeding up to 2 years or beyond

Other: ______________________________

Check availability of:

IEC material on exclusive and continued

breastfeeding

Poster with Ten Steps to Successful Breastfeeding

Protocol/guidelines for health workers on

breastfeeding counselling

Other: ______________________________

Counselling and

support for

appropriate

complementary

feeding

Yes No

All mothers

Other:_______


Timely introduction of complementary foods (i.e. at 6 moths)

Continued frequent, on-demand breastfeeding until 2 years or

beyond

Good hygiene and proper food handling practice

Variety of food to ensure that nutrient needs are met

Appropriate amount and frequency of meals (i.e. increase the

number of times and the amount of complementary food as the

child gets older)

Fortified complementary foods or micronutrient supplements, as

needed

Other: _______________________________


IEC material on complementary feeding


complementary feeding counselling

IEC material on hygiene and food safety (i.e. 5 Keys

to Safer Food)

Other: ______________________________

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Home fortification of

foods with multiple

micronutrient

powders

Yes No

Children 6-23 m

Other:_______


Information on the product and its correct use and hygienic

practices


Appropriate complementary feeding

Other: _______________________________


IEC material on home fortification with multiple

micronutrient powder

Protocol/guidelines for health workers on multiple

micronutrient powder

Sachets with mulitple micronutrients

Dose: Iron_____mg Zinc: _________mg

Vitamin A _______IU or ________RE

Other:________

Status Not expired Expired

Other: ______________________________

Counselling and

support for

appropriate feeding

of low birth weight

(LBW) infants

Yes No

Mothers or

caregivers of LBW

infants

Other:_______


Kangaroo care

Appropriate feeding practice (breast milk feeding unless valid

reason for use of breast milk substitute)

Other: _______________________________


IEC material on LBW

IEC material on kangaroo care


counselling and support for appropriate feeding of

LBW infants

Other: ______________________________

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Vitamin A

supplementation

Yes No

Children 6-59 m

Children

suffering from

measles

Other:_______

When to provide vitamin A supplementation?

If vitamin A deficiency is a public health problem in the

communities or areas

As part of the management of measles (i.e. to prevent measles

related penumonia)

Other: ______________________________


IEC material on prevention of vitamin A deficiency

Protocol/guidelines for health workers on vitamin A

supplementation

Protocol/guidelines for health workers on vitamin A

in measles management

Vitamin A supplements

Dose: _______IU or ________RE

Frequency: __________


Other: ______________________________

Iron supplementation

Yes No

Children 24 m -

12 y

Other:_______

When to provide iron supplementation?

If anaemia prevalence is more than 20% in the communities or

areas

Other:__________________________

How often? Intermittent Other:____________________


IEC material on prevention of iron deficiency

anaemia

Protocol/guidelines for health workers on iron

supplementation

Iron supplements: Dose: _______mg

Status: Not expired Expired

For assessing anaemia, HemoCue or other method

for measuring Hb

Other: ______________________________

Anaemic

children 6 m -12 y

Other:_______

How often? Daily Other:____________________

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Management of

severe acute

malnutrition (SAM)

Yes No

Children with

SAM with

complications

How to treat children with SAM with complications?

Treatment or prevention of complications (i.e. hypoglycaemia,

hypothermia, dehydration, septic shock, etc)

Appropriate formula diets

Treatment of infection

Treatment of other problems (i.e. vitamin deficiency, severe

anaemia, heart failure, etc)

Support to restablish or continue breastfeeding

Other: _______________________________


IEC material on severe acute malnutrition

Protocol/ guidelines for health workers on treatment

of children with SAM covering children with

and/or without complications

National protocol WHO guidelines

Other: _________________________

Register for children with SAM

Functioning baby weighing scale

Length measuring board

Height measuring board

Growth charts or health cards with growth curves

WHO Growth Standards Other:__________

MUAC tapes

For SAM with complications:

Formula diet Type: F-100 F-75


Drugs for treatment Antibiotics Resamol

For SAM without complications:

Ready-to-use therapeutic food

Type: _________ Target age group: _________


Other: ______________________________

Children with

SAM without

complications

How to treat children with SAM without complications?

Nutritional rehabilitation with appropriate, locally available nutrient-

dense food

Nutritional rehabilitation with ready-to-use therapeutic food (except

for children under 6 months)



Other: _______________________________

Other:_______

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Management of

moderate acute

malnutrition (MAM)

Yes No

Children with

MAM

Other:_______

How to treat children with MAM?

Dietary counselling



Food supplements

Clinical care

Other: _________________________________


IEC material on severe acute malnutrition

Protocol/guidelines for health workers on treatment

of children with MAM

Register for children with MAM

Food supplements

PEM (Protein-Energy Malnutrition) porridge

Supplementary food packages


Functioning baby weighing scale

Length measuring board

Height measuring board

Growth charts or health cards with growth curves

WHO Growth Standards Other:__________

MUAC tapes

Other: ______________________________

Zinc

supplementation

Yes No

Children with

diarrhoea

Other:

__________

When to provide zinc supplementation?

For managing diarrhoea, together with ORT

Other:__________________________


IEC material on prevention of diarrhoea

IEC material on zinc supplementation in diarrhoea

management

Protocol/guidelines for health workers on zinc

supplementation for diarrhoea management

Zinc supplements: Dose: _______mg


Oral Rehydration Therapy (ORT)

Other: ______________________________

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Counselling and

support on infant

and young child

feeding in the

context of HIV

Yes No

Mothers with

HIV or AIDS

Other:________



Continued breastfeeding up to 12 months

Antiretroviral therapy or prophylaxis to mothers or infants

If not breastfed, access and safe conditions for formula feeding

Other:________


IEC material on infant and young child feeding in

the context of HIV

Protocol/guidelines for health workers on infant and

young child feeding in the context of HIV

Antiretroviral therapy or prophylaxis for mothers

Antiretroviral therapy or prophylaxis for infants

Other: ______________________________

Nutritional care and

support of children

infected with HIV

Yes No

Children

infected with HIV

Other:_______

What care to give?

Antiretroviral therapy

Diet to ensure additional energy intake

Other:________


IEC material on nutritional care of children with HIV

Protocol/guidelines for health workers on nutritional

care of children with HIV

Antiretroviral therapy for children

Other: ______________________________

Iron and folic acid

supplementation

Yes No

All pregnant

women How often? Daily Other:____________________


IEC material on prevention of anaemia

Protocol/guidelines for health workers on iron and

folic acid supplementation for pregnant women

Iron and folic acid supplements

Dose: Iron_____mg Folic acid_____mg


For assessing anaemia, HemoCue or other method

for measuring Hb

Other: ______________________________

Non-anaemic

pregnant women

How often? Intermittent (i.e. weekly)

Other: ________________________

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Iron and folic acid

supplementation

Menstruating

women

When to provide iron and folic acid supplementation?

If anaemia prevalence is ≥20% in the communities or areas

Other:__________

How often?

Intermittent (i.e. weekly)

Other:_______


IEC material on prevention of anaemia

Protocol/guidelines for health workers on iron

supplementation for menstruating women

Iron supplements: Dose: _____mg


Other: ______________________________

Other:________

Calcium

supplementation

Yes No

Pregnant

mothers

Other:_______

When to provide calcium supplementation?

For prevention of pre-eclampsia/eclampia

Other:__________________________


IEC material on calcium supplementation for

prevention of preeclampsia/eclampsia

Protocol/guidelines for health workers on calcium

supplementation for prevention of

preeclampsia/eclampsia

Calcium supplements Dose: ______mg


Other: ______________________________

Folic acid

supplementation

Yes No

Menstruating

women

Other:_______

When to provide folic acid supplementation?

Periconception (i.e. if trying or likely to get pregnant), especially if

no regular iron and folic acid supplementation is taken

Other:__________________________


IEC material on prevention of folic acid

supplementation for pregnant women

Protocol/guidelines for health workers on folic acid

supplementation for pregnant women

Folic acid supplements Dose:_________mg


Other: ______________________________

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Iodine

supplementation

Yes No

Pregnant and

lactating women

Other:_______

When to provide iodine supplementation?

Household coverage of iodized salt < 20% and there is no plan to

scale-up salt iodization

Other:__________________________

How often?

Daily Annual Other:_______


IEC material on prevention of iodine deficiency

disorders

Protocol/guidelines for health workers on iodine

supplementation for pregnant and lactating women

Iodine supplements Dose:_________μg


Other: ______________________________

Appropriate care of

women with low

body mass index

Yes No

Women with

BMI < 16 kg/m2

Other:_______

What care to give?

Formula diets (with added minerals and vitamins)

Management of hypothermia and hypoglycaemia

Systemic antibiotics

Vitamin A supplementation (Single dose of 200 000 IU except for

pregnant women)


IEC material on nutrition, diet and health for

prevention of undernutrition

Protocol/guidelines for health workers on care for

women with low body mass index

Formula diet Type:_________


Vitamin A supplements

Dose: _______IU or ________RE


Other: ______________________________

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?






support for HIV-

infected pregnant

and lactating women

Yes No

Pregnant

women with HIV or

AIDS

Mothers with

HIV or AIDS

Other:_______

What care to give?

Antiretroviral therapy for pregnant women

Diet to ensure additional energy intake

Other:_______


IEC material on nutrition during pregnancy and

lactation in the context of HIV

Antiretroviral therapy or prophylaxis for pregnant

women

Protocol for health workers on nutritional care and

support for HIV infected pregnant and lactating

women

Other: ______________________________


support in

emergencies

Yes No

Pregnant

women

What care to give?

Multiple micronutrient supplementation

Access to food, cash and/or voucher transfers to meet nutrition

needs

Early initiation of breastfeeding within 1 hour



Other: ______________________________


IEC material on nutritional care and support during

emergencies

Protocol/guidelines for health workers on nutritional

care and support in emergencies

Protocol/guidelines for health workers on multiple

micronutrient supplementation for pregnant women

Mulitple micronutrients supplements

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?






support in

emergencies

Breastfeeding

mothers

What care to give?

Supplementary feeding using dry rations or ready-to-use foods

(regardless of maternal nutritional status)

Access to food, cash and/or voucher transfers to meet nutrition

needs



Other: ______________________________

Dose: Iron_____mg Folic acid_____mg

Vitamin A _______IU or ________RE

Zinc: ______mg Other:________


Target group: Pregnant women

Children Other:___________


supplementary feeding for lactating women

Supplementary foods

Type: _________________


Target group: Lactating women Other:______

Other: ______________________________

Mothers or

caregivers of

infants and young

children 6 - 23

months

What care to give?

Timely introduction of complementary foods (i.e. at 6 moths)

Continue frequent, on-demand breastfeeding until 2 years or

beyond


Variety of food to ensure that nutrient needs are met

Appropriate frequency of meals (i.e. increase the number of times

that the child is fed complementary foods as he/she gets older)

Use of fortified complementary foods, micronutrient powders or

mulitple micronutrient supplements, as needed

Other: _______________________________

Other:_______

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Nutrition education

Yes No

All

Other:_______


Promotion of healthy eating for prevention of undernutrition

Promotion of healthy eating for prevention of micronutrient

deficiencies

Promotion of healthy dietary practices and physical activity for

prevention of overweight/obesity and non-communicable diseases

(NCD)

Promotion of food hygiene, safe handling of food and clean water

Other: ______________________________



prevention of undernutrition


prevention of micronutrient deficiencies

IEC material on promoting healthy dietary practicies

and physical activity (i.e. 3 Fives)

Food-based dietary guidelines, food guide and other

nutrition education materials

IEC material on hygiene and food safety (i.e. 5 Keys

to Safer Food)

Training material (modules, CDs, videos etc)

Other: ______________________________

Promotion of hand

washing with soap

Yes No


IEC material on handwashing with soap

Other: ______________________________

Deworming

Yes No

Pregnant

women

Children

Adolescents

Other:_______


IEC material on deworming

Protoocl/guidelines for health workers on

deworming

Antihelmintics

Other: ______________________________

Interventions

Does your facility

provide…

Target group(s)

Who receives the

intervention?





Promotion of the use

of insecticide-treated

bed nets

Yes No


IEC material on prevention of malaria

Protocol/guidelines for health workers on prevention

of malaria

Other: ______________________________

Family planning /

pregnancy spacing

Yes No

Reproductive

age women

Reproductive

age men

Other:_______


IEC material on family planning / pregnancy spacing

Other: ______________________________

Other interventions: Target groups: Details: Supplies and material:

2.4 Does your facility provide nutrition education in group?

Yes No Don't know

2.4.1 If yes, please describe:

Who is responsible for

nutrition group education in

your facility?

What relevant training does

he/she have?

Where are sessions held?

How often are sessions

held?

What topics are covered

during sessions?

Which tools or materials

are being used?

Who are participating in

sessions? Approximately

how many receive nutrition

group education per

month?

2.5 Describe how one-to-one counselling in nutrition takes place in your facility Probe: Who is responsible, when and where does it take place

Who is responsible for

nutrition counselling in your

facility?

What relevant training does

he/she have?

Where does nutrition

counselling take place?

How often does it take

place?

What topics are being

discussed during nutrition

counselling?

Which tools or materials

are being used?

Who are the beneficiaries?

Approximately how many

receive one-to-one

counselling in nutrition per

month?

2.6 How does your facility work with communities to improve nutrition? Describe any community mobilisation activities that your facility has initiated or taken part in, if exist. Probe: role of volunteers, husbands, TBAs, community leaders etc.

2.6.1 Are there any breastfeeding support groups or volunteers based at your facility or in the local community? E.g. BFHI support groups

2.6.2 If breastfeeding support groups exist, how often do they meet?

2.7 Has your facility ever received any free formula milk samples or posters, pamphlets, paper pads, pens etc. from formula manufacturing companies?

Yes No Don’t know

If yes, please describe:

2.8 Do you feel that ongoing activities address the nutrition problems and underlying causes that you mentioned?

Yes No Don't know

2.8.1 What are the areas of success, what are the areas that need to be improved, and what are your specific suggestions to improvement?

Areas of success:

Areas that need to be improved:

Specific suggestions to improvements:

Section 3. Management of the nutrition programme

3.1 Is there a person responsible for managing the nutrition programmes in your facility?

Yes No Don't know

If yes,

3.1.1 What training in nutrition has he/she received?

3.1.2 What proportion of his/her time is spent on counselling patients on nutrition?

Proportion: %

3.2 Who else is usually providing nutrition services at your facility on a day-to-day basis?

Facility manager

Physician

Nurse

Enrolled nurse

Midwife

Dietician

Health worker

Volunteers / Lay counsellors

Administrator / Clerk

Other:________________________

Section 4. Training

4.1 What nutrition related training have the staff currently working in your facility received?

Nutrition-related training Staff who have received this training

Number Category

4.2 Is there any system for follow-up training or monitoring of the effect of training provided, such as on-site or refresher training?

Yes No Don't know


Section 5. Support

5.1 Do you have any contact with nutrition programme staff at district or provincial/regional level?

Yes No Don't know


5.1.1 How often do you meet with the district or provincial/regional nutrition programme staff?

Every week Every month Every 2-3 months Less often

5.2 Do you feel that your facility receive adequate support from the district or provincial/regional nutrition programme staff?

Yes No Don't know


5.2.2 If no, why not and what are your specific suggestions to improvement?


6.1 In your opinion, what are the top three priority needs of your facility in order to accelerate reduction of malnutrition?

6.2 Is there anything else that you would like to add regarding the nutrition services in this

facility?



Form 5. Health workers

Structured questionnaire interview for all clinic staff

providing services to pregnant women or children

ID:___

Completed by:


starting the interview :







we are seeking to get your views on current nutrition challenges and how health

workers in your facility respond to these.


NAFIN, Synergos, USAID, CDC and line ministries. We have split into 4 teams and

are interviewing stakeholders at the national, provincial/regional, district, and facility

level in 4 field locations.

This interview is a tool to learn more about how health workers in general at your

facility implement nutrition activities. In particular, we would like to profit from the

knowledge and experience that you have through working in nutrition in the area. The

interview will take approximately 20-30 minutes.


will be shared and presented at a consensus meeting on a future date. We are

confident that your invaluable inputs will enrich the analysis and contribute to the

formulation of relevant recommendations."

Date of

visit

d d m m y y y y

Region: District:

Facility: Unit:

Intermediate/ Intermediate Refferal

Hospital

District Hospital

Referral Hospital

Clinic

Health Centre

Maternity/Birthing Unit

Other: _________________________ ___

Out-Patient Department Maternity/Birthing Unit Children’s (pediatric) ward Other: ______________________ ______

Respondent:

Name:

Position:

Background:

Section 1. Training

1.1 In the last two years have you been trained in:

Maternal nutrition Yes No

Infant and young child nutrition Yes No

Breastfeeding Yes No

Complementary feeding Yes No

Counselling skills Yes No

Micronutrients Yes No

Nutritional care of sick children Yes No

Management of severe or moderate malnutrition Yes No

Growth monitoring and promotion Yes No

Healthy diets (including use of locally available food) and

physical activity Yes No

Hygiene and food safety Yes No

Other: __________________ Yes No

1.2 Are there any areas in nutrition which you feel that you need more training?

Yes No

If yes, please describe the nutrition areas and also types of training:

Section 2. Knowledge of nutrition guidelines and protocols

Ask the question and give time for the respondent to answer. If necessary read out the

options. 2.1 What micronutrient supplement should pregnant women receive?

Iron only Folic acid

only

Iron and

folic acid

Iron and

folic acid,

calcium

Iron and

folic acid,

calcium, and

iodine

(where salt

iodization is

inadequate)*

Don’t know

2.2 How soon after delivery should a baby be put to the breast?

Within 1 hour* Within 6 hours Within 24

hours

After the

mother has

recovered

Don’t know

2.3 When should breastfed children start receiving complementary foods?

At 4-6 months

of age

At 6 months of

age*

At 8 months of

age

When the child

has got teeth

Don’t know

2.4 Should all infants receive vitamin A supplements?

Yes

No, only if living in areas where

vitamin A deficiency is a public

health problem, or if suffering

from measles*

Don’t know

2.5 Zinc supplements should be given to all children who have diarrhoea

True* False Don’t know

2.6 All children in all countries have the same potential to grow from birth until 5 years,

which is relfected in the WHO Growth Standards


2.7 Children with severe acute malnutrition with complications or younger than 6 months should be admitted for in-patient treatment.


2.8 Exclusively breastfeed infants who get diarrhoea may need some water to replace loss

of fluids.

True False* Don’t know

2.9 HIV-infected women who choose to breastfeed should practice exclusive breastfeeding up to 6 months and continued breastfeeding until 12 months.


2.10 Overweight and obesity are the problems of the high income segment of the society so

education on balanced diets and healthy lifestyle is not necessary in poor communities

True False* Don’t know

2.11 How soon after delivery should a baby’s umbilical cord be clamped?

Straight away After one

minute

After 3

minutes* After 1 hour

Don’t know

2.12 Which protocol do you use for the management of severe acute malnutrition of children?

Do NOT prompt for the options listed

National protocol for

Management of

Severe Acute

Malnutrition

WHO Guidelines for

the inpatient

treatment of severely

malnourished children

Other, please

describe:

Don’t know

Section 3. Programme implementation

Please select only one response in this section

3.1 How relevant is the education qualifications you have received to your current nutrition tasks?

Not relevant at

all Partly relevant Relevant Very relevant

Not applicable

3.2 How relevant is the continuous professional development training you have received to your current nutrition tasks?

Not relevant at

all Partly relevant Relevant Very relevant

Not applicable

3.3 In your everyday work, has your training (pre- and in-service) adequately prepared and equipped you to implement the nutrition actions in your facility (i.e. hospital, health clinic, health centre, health post, etc)?

Not confident

at all

Confident

about some

aspects

Confident

about most

aspects

Confident

about every

aspect

Not applicable

3.4 In your everyday work, has your training (pre- and in-service) adequately prepared and equipped you to advise and support a breastfeeding mother to exclusively breastfeed for 6 months?

Not confident

at all

Confident

about some

aspects

Confident

about most

aspects

Confident

about every

aspect

Not applicable

3.5 In your everyday work, has your training (pre- and in-service) adequately prepared and equipped you to advise mothers about complementary feeding?

Not confident

at all

Confident

about some

aspects

Confident

about most

aspects

Confident

about every

aspect

Not applicable

3.6 In your everyday work, has your training (pre- and in-service) adequately prepared and equipped you to interpret World Health Organisation (WHO) growth charts?

Not confident

at all

Confident

about some

aspects

Confident

about most

aspects

Confident

about every

aspect

Not applicable

3.7 In your everyday work, has your training (pre- and in-service) adequately prepared and equipped you to treat severely malnourished children?

Not confident

at all

Confident

about some

aspects

Confident

about most

aspects

Confident

about every

aspect

Not applicable

3.8 In your everyday work, has your training (pre- and in-service) adequately prepared and equipped you to counsel a mother/caregiver about the feeding of sick children?

Not confident at

all

Confident about

some aspects

Confident about

most aspects

Confident about

every aspect Not applicable

3.9 In your everyday work, has your training (pre- and in-service) adequately prepared and equipped you to counselling HIV-infected women about infant feeding?

Not confident at

all

Confident about

some aspects

Confident about

most aspects

Confident about


3.10 In your everyday work, has your training (pre- and in-service) adequately prepared and equipped you to advice about diet and physical activity to prevent overweight?

Not confident at

all

Confident about

some aspects

Confident about

most aspects

Confident about


3.11 If any of the responses (3.2 – 3.9) have been Not confident at all/ Confident about some

aspects, list the aspects where you feel you need up-skilling.

Section 4. Counselling

4.1 How do you counsel a mother with breastfeeding difficulties?

Ask the health worker to describe a regular counselling session with a mother with breastfeeding difficulties.

What questions will he/she ask the mother?

What signs will he/she look for?

Will he/she talk in a certain way with the mother?

Breastfeeding difficulties: The health workers mentions that he/she

Considers baby's positioning relative to the mother

Considers baby's attachment to the breast

Considers suckling

Looks for other signs, e.g. mother health status, breast condition, etc

Counselling skills: the health worker mentions that he/she

Listens to and learn from mothers20

Builds confidence and give support21

Other:

20

Examples of skills related to listening and learning: Use helpful non-verbal communication (e.g. eye contact, head level contact, take time), ask open questions, use responses and gesture that shows interest, reflect back what the mother says, empathise through showing understanding of mother's feeling, and avoid words which sounds judging

21 Examples of skills related to building confidence and giving support: Accepting what a mother feels, recognize and

praise what a mother is doing right, give practical help, give a little but relevant information in a positive way, use simple language, make one or two suggestions - not commands

4.2 How do you counsel a mother/caretaker whose child is not growing adequately according to the growth chart?

Ask the health worker to describe a regular counselling session with a mother/caretaker of a child who is not growing well.

What questions will he/she ask the mother?

Will he/she talk in a certain way with the mother?

How will you make sure that the mother follows advice?

Inadequate growth: The health workers mentions that he/she

Involves mother in identifying underlying problems related to deviation from good feeding

practice, i.e.

Exclusive breastfeeding for infants up to 6 months

Continued frequent, on-demand breastfeeding until 2 years or beyond


Variety of food to ensure that nutrient needs of children are met

Appropriate amount and frequency of meals (i.e. increase the number of times and the

amount of complementary food as the child gets older)

Fortified complementary foods or micronutrient supplements, as needed

Gives some few practical and feasible advice

Sets goals with the mother

Checks that the mother has understood

Counselling skills: the health worker mentions that he/she

Listens to and learn from mothers22

Builds confidence and give support23

Other:

22

Examples of skills related to listening and learning: Use helpful non-verbal communication (e.g. eye contact, head level contact, take time), ask open questions, use responses and gesture that shows interest, reflect back what the mother says, empathize through showing understanding of mother's feeling, and avoid words which sounds judging

23 Examples of skills related to building confidence and giving support: Accepting what a mother feels, recognize and

praise what a mother is doing right, give practical help, give a little but relevant information in a positive way, use simple language, make one or two suggestions - not commands

4.3 How do you counsel a mother about breastfeeding in the context of HIV?

Ask the health worker to describe a regular counselling session. What questions will he/she ask the mother? What signs will he/she look for? Will he/she talk in a certain way with the mother? In what way will he/she give advice? Ask the health worker to summarise the 2011 Infant and Young Child Feeding Guidelines.

What questions will you ask the mother?

What signs will you look for?

In what way will you talk to the mother/caregiver?

In what way will you give advice?

Summary of Infant and Young Child Feeding Guideline 2011


4.4 How do you counsel a mother on the feeding of a sick child?

Ask the health worker to describe a regular counselling session. What questions will he/she ask the mother?

What signs will he/she look for? Will he/she talk in a certain way with the mother? In what way will he/she give advice? Ask the health worker to summarise the 2011 Infant and Young Child Feeding Guidelines.

What questions will you ask the mother?

What signs will you look for?

In what way will you talk to the mother/caregiver?

In what way will you give advice?

Summary of Infant and Young Child Feeding Guideline 2011


4.5 How do you ensure follow-up with these mothers?

Mother with breastfeeding difficulties

A child who is not growing adequately according to the growth chart

Infant and young child feeding in the context of HIV

Feeding of a Sick Child

4.6 Do you feel that your advice and support to mothers help improve nutrition?

Yes No Don’t know

If Yes, please describe indicators of improved malnutrition:

If no, please give possible reasons as to why not.

4.7 What are the main challenges you are facing when you counsel mothers/caretakers?

4.8 Has your facility (i.e. hospital, health clinic, health centre, health post, etc.) ever received any free formula milk samples or poster, pamphlets, paper pads, pens, by formula manufacturing companies?

Yes No Don’t know


4.9 Do you give nutrition related health education in your facility?

Yes No Don’t know

If Yes, please describe education given:

If yes, how often do you carry out nutrition related health education?

Everyday Every week Every fortnight Monthly Other (please specify)

______

Section 5. Support

5.1 If you need support in nutrition related activities; do you have access to the resources

(information or human) to answer questions you have?

Yes No Don’t know

5.1.1 If you have access to technical support, what is your source of support regarding nutrition? Technical support includes help with difficult counselling cases, information about

recent advances in nutrition

5.2 Is the support you are receiving regarding nutrition adequate? If no, please give

possible reasons to barriers for support

Yes No Don’t know

If no, possible barriers for support :

5.3 Are there specific suggestions to how the support could be improved?

5.4 Do you have adequate time in your job to carry out your nutrition duties?

Yes No Don’t know

If no, please give possible reasons:


6.1 Please list the nutrition activities that are currently ongoing in this facility.

6.2 In your opinion, how can the nutrition programme be improved?

6.3 Is there anything else that you would like to add regarding the implementation of

nutrition services in this facility?



Form 6. NGO field office

Semi-structured interview with management and/or

nutrition programme officer of NGO providing services to

women and children

ID:___

Completed by:


starting the interview :







we are seeking to get your views on current nutrition challenges and how your

organisation responds to these.


NAFIN, Synergos, USAID, CDC and line ministries. We have split into 4 teams,

where some of us are interviewing stakeholders at the national level and others are

doing interviews at regional, provincial, district and facility level in 4 field locations.


organisation's current activities which relate to nutrition. In particular, we would like to

profit from the knowledge and experience that you have through working in nutrition

in the area. Your answers will be treated with confidentiality. The interview will take



will be shared and presented at a consensus meeting on a future date. We are

confident that your invaluable inputs will enrich the analysis and contribute to the

formulation of relevant recommendations."

Date of visit

d d m m y y y y

Region: District:

NGO name:

NGO type:

International NGO, sub-office

National NGO

Local NGO

Community-Based Organisation (CBO)

Faith-Based Organisation (FBO)

Civil Organisation

Other: ________________________

Respondent:

Name:

Position:

Background:


1.1 What do you perceive as the major nutrition problems in your country and what are the

most important causes of these problems? If the respondent only mentions underlying causes (e.g. poverty, lack of education, etc), try to obtain

information on how the respondent sees those underlying causes affect the nutrition status of people (e.g. how does poverty affect nutrition among children).

Problems mentioned:



Stunting:

Wasting:



Other:








Lack of knowledge:

Poverty:

Natural disasters:

Other:

Section 2. NGO mandate and activities

2.1 What is the primary focus of your organisation?

2.2 What nutrition programmes and interventions are you currently implementing?

Please include information regarding programmes and the specific interventions included in these programmes using the table overleaf.

Please note that some indicators (i.e. area and status of programme, target group and delivery channel of interventions) should be answered using the predefined answering options listed above the table.


2.3 In addition to the programmes and interventions mentioned, are you planning to implement other nutrition activities?

2.4 Does your organisation work with communities to improve nutrition?

Yes No Don't know

2.4.1 If yes, describe any community mobilisation activities that your organisation

has initiated or taken part in Probe: role of volunteers, husbands, TBAs, community leaders etc.

2.4.2 Is there any breastfeeding support group or volunteers in the local

community?

2.4.3 How often do they meet?







Title:




Target

group

Select

Budget and


channel

Select

Coverage

Number of

beneficiaries

M&E system

Who is

responsible for

M&E

M&E

indicators

Indicators used

in M&E

Comments

Please note

additional comments

Region

Amount

budgeted

Amount

secured

District:

1.

Area

2.

Status

3.

Start date

4.

End date

5.

Implementing

Partners:

6.

7.

Budget

8.

Funding secured*

9.

Funding source

10.

*Amount or %

Section 3. Budget

3.1 What is the annual budget of your organisation that is dedicated to nutrition-related activities. Approximately what percentage does this represent of the total budget of your organisation ?

Annual budget for nutrition-related activities Approximate % of total budget

Current year: N$

Last year: N$

3.2 What are the sources of funding for nutrition activities implemented by your organisation? How large part of the nutrition budget within your organisation does each one represent?

Main donors to nutrition budget % of nutrition budget

1.

2.

3.

4.

5.

3.3 Has your organisation received any specific funding from or been contracted by relevant

Offices/Ministries/Agencies for nutrition interventions in the past one year?

Yes No Don't know


Type of intervention Government agency who

provided funds

Approximate amounts

Section 4. Responsibilities and cooperation with partners

4.1 Who is responsible for managing the nutrition programmes in your organisation?

4.1.1 What is his/her background or what kind of training does he/she have?

4.1.2 What proportion of his/her time is spent on counselling patients on nutrition?

Proportion: %

4.1.3 What training has he/she received in nutrition since he/she joined your organisation?

4.2 In the area of nutrition, describe your organisation’s working relationship with relevant Offices/Ministries/Agencies that your organisation cooperates with (e.g. Ministries of Health, Food

and Agriculture, Women’s Affairs, Education)

Offices/Ministries/Agencies Function

4.3 Are you working with any partners in implementing nutrition programmes or activities?

Yes

No

If yes,

4.3.1 Can you give some examples of successful partnerships in nutrition and indicate the reasons why these partnerships are successful?

4.3.2 What are your suggestions to how partners could work better together to improve nutrition? Give examples of areas to improve. Please give possible reasons as why partnerships have not been successful.

4.4 How are nutrition activities coordinated in the area? What are the institutional arrangements/platforms?

If coordination mechanism (e.g. working group, task force, committee, etc.) exists:

4.4.1 Are you participating?

4.4.2 How often do you attend meetings?

Frequency of attendance:

4.4.3 If your organisation never or seldom attend meetings, why not?

Describe:

Section 5. Training

5.1 Does your organisation offer any training relevant to nutrition?

Yes No Don't know

5.1.1 If yes, please indicate the topic, duration, participants and training material used

related to these trainings?

Topics of training relevant to nutrition

Duration of the

training


Training material used (Title, language, year of publication)

5.1.2 Have staff from other agencies been invited to take part in trainings your organisation offers?

Yes No Don't know

Describe:


Describe:


Describe:

5.2 How many of the current staff in your organisation have received training in each of the following areas:

Areas of nutrition training: Number of staff trained

Maternal nutrition

Infant and young child nutrition

Breastfeeding

Complementary feeding

Counselling skills

Micronutrients

Nutritional care of sick children

Management of severe or moderate malnutrition

Growth monitoring and promotion

Healthy diets (including use of locally available food) and

physical activity

Hygiene and food safety

Other:______________________________________

5.2.1 How many of the above staff who have received nutrition training are still working

at your organisation?

All Most Some None Other Don’t know

Section 6. Nutrition information

6.1 Does your NGO routinely collect nutrition indicators?

Yes No Don't know

6.1.1 If yes, what types of nutrition-related information/data does your organisation collect? Please describe indicators collected, target population groups surveyed and how often data are collected.

Nutrition-related indicators

collected


data?

6.1.2 With whom do you share this information?

6.2 Have you ever received information from relevant Offices/Ministries/Agencies, UN agencies, bilateral agencies or other nongovernmental organisations on the nutrition situation in the areas where your organisation is working?

Yes No Don't know


6.3 How does your organisation use the collected data or any other available nutrition-related data from governmental offices, UN agencies, bilateral agencies or other nongovernmental agencies?


7.1 What are the main obstacles, if any, that have hindered the implementation of your organisation’s nutrition activities?

7.2 In your opinion, what is the top priority of this province/region, district or community in order to improve nutrition?

7.3 With the current level of resources, if your organisation could do only one thing at scale to improve nutrition – what would that be?

7.4 Is there anything else that you would like to add regarding the nutrition services offered by your organisation?



LANDSCAPE ANALYSIS TO ACCELERATE ACTIONS TO IMPROVE … · This Nutrition Landscape Analysis report...

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