Nutrition for Growth
Transcript of Nutrition for Growth
October 2014CIFF Nutrition StrategyNutrition for Growth
Supporting the transformation of how maternal and child undernutrition is prioritised, planned, resourced and delivered globally to reach the 2020 Nutrition for Growth & 2025 World Health Assembly targets
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Contents
1. Nutrition: current situation
2. Theory of change
3. CIFF objectives
4. CIFF “star” approach: transformational country programmes and global influence
5. Conclusion
• Focussing on interventions with the highest likelihood of impact• Country investment approach: achieving our 30% stunting reduction target by
working with governments, businesses and civil society • Global work: complementing country investments, drawing from them and
magnifying their impact• Country selection• Operating principles
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Undernutrition continues to be one of the most significant issues preventing children and societies from reaching their full potential
The double burden of over and undernutrition is a global issue of huge proportions. CIFF is prioritising the burden of undernutrition, which remains unacceptably large, and two of its manifestations are particularly alarming:
Stunting, a societal issue resulting in poorer education outcomes and limiting future wage earning ability, as well as increasing risk of disease and death:
• 1 in 4 children, or 162m under-5 children
• In 2012 >90% stunted children concentrated in Africa and Asia
Severe wasting has very high risk of death: 17m children suffer from Severe Acute Malnutrition*
1. Nutrition: current situation
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Eliminating undernutrition in young children can provide tremendous benefits
1. Nutrition: current situation
Growing Economies Policy Brief : IDS (Lawrence Haddad)- CIFF*http://www.who.int/nutgrowthdb/jme_2012_summary_note_v2.pdf?ua=1
Source:
Boost GNP even further by taking full advantage of the demographic dividend
Prevent 45% of child mortality
Reduce burden of disability for children under 4 by more than half
Increase school attainment by at least one year
Boost wage rates by 5-50%
Make children 33% more likely to escape poverty as adults
Make women 10% more likely to own their own business when they become adults
Break intergenerational poverty cycle: stunted mothers 3x as likely to have malnourished infants
Boost Gross National Product (GNP) by 11% in Africa and Asia
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Momentum is building: knowledge, political commitment, global trends and number of success stories are all on the rise
• Increased knowledge on what works (e.g., Lancet 2008, 2013)
• Increasing momentum (e.g. Scaling Up Nutrition movement, Nutrition for Growth) and funding
• Global reduction in stunting prevalence from 40% to 26% between 1990 and 2010, with a large share attributable to China
• Significant reductions in countries of every region:
Source: World Health Organisation
*in at least one inter-survey period (range: 3-5y)
1. Nutrition: current situation
Prevalence has dropped by more than
2.0%/year at least once
Prevalence dropped by more than 1.5%/
year at least once
Prevalence not dropping by more than 1.5%
any year
No data
Over the last two decades, prevalence has dropped at least once* by over 1.5 percentage points per year in every region
2 percentage points per year Absolute reduction achieved by top performers
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Both Nutrition for Growth, and the World Health Assembly, set ambitions to change the state of the world
*Lancet 2013, based on UN estimates of future stunting prevalence; reduction rate inferred from prevalence reduction 26%-20% over 15 years. Several countries, particularly in Africa are not on this current average trajectory and will require an even greater change in pace for World Health Assembly targets to be met**Lancet 2013: annual cost of scaling-up a package of 10 essential nutrition-specific interventions to 90% coverage in the 34 countries where 90% of the world’s stunted children live.
Nutrition for Growth (N4G) targets require increasing the pace of stunting reduction by a factor of 2-3
World Health Assembly target of a 40% reduction in the number of children who are stunted by 2025
1. Nutrition: current situation
Evolution of stunting burden over the next 15 years
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103
125
148
170
2010 2015 2020 2025
Glo
bal s
tunt
ing
burd
en (m
illio
ns)
Trajectory to reach both N4G target (2020) and World Health Assembly target (2025) for stunting
Nutrition for Growth target of reducing stunting by 20 million by 2020
World Health Assembly target of a 40% reduction in the number of children who are stunted by 2025
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Estimated current trajectory
2. Theory of change
Nutrition for Growth and WHA targets met
Societal recognition that solving malnutrition is a feasible and affordable political goal, with huge economic and social benefit
Enabling environment for planning, resourcing and
delivery of nutrition
Government leaders lobby for resources & cross-sectoral action
Business leaders make economic case for nutrition, ensure product availability and demand change
Planning for scale and sustainability, with improved institutions and monitoring & evaluation
Innovation of services, products & delivery systems
New interventions & products that increase expected impact of the nutrition toolkit
Aggressive cost reduction of interventions, products & essential platforms such as community nutrition promoters
Creation of ‘safe space’ for innovation in government and private companies
ImprovedData and Knowledge
Increased transparency & accountability on country & donor commitments and spend
Transformational nutrition programmes at
scale
Strengthened platforms for delivery at scale of nutrition specific and nutrition sensitive interventions
Strengthened management of multisectoral nutrition interventions, coupled with appropriate incentives and accountability mechanisms
National scale-up of high impact interventions within multiple platforms
Coverage of stunting and severe acute malnutrition interventions measured
Documentation and dissemination of individual and collective success stories
New business models to increase the penetration of nutritious products and interventions in base-of-the-pyramid markets
Nutrition budgets and ODA increased
Traditional / community leaders & civil society organise behaviour change & programme implementation
Increased private spend on high-impact nutrition products
Nutritional status indicators measured regularly in country surveys
Research and documentation on delivery science and cost-effectiveness
What the world needs to do: create a sense of urgency at national and global levels, and a clear path to tackle undernutrition…
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Conducive environment: gross national income, infrastructure level, trade policies, etc.
… and strengthened platforms for delivery at scale, harnessing the agency of individuals, communities and civil society to
promote, enable and sustain behaviour change
2. Theory of change
Small retailers enable access to affordable products for the community
Individuals
Households and caretakers demand adequate products and services, influence their neighbours, and change mothers’ and children’s daily feeding and hygiene practices
Civil society
CSOs can empower communities with knowledge, help shape social norms, and improve access to services
Frontline health and agricultural workers are the most credible source of information and the most cost effective delivery channel
Community leaders influence and organize to turn healthy practices into social norms
Community
Society recognizes good nutrition as a key contributor to health and productivity
Improved nutrition of mothers and children
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Support the transformation of how
maternal and child undernutrition
is prioritised, planned, resourced and delivered globally to reach the 2020 Nutrition for Growth
& 2025 World Health Assembly targets
Our objective
3. CIFF objective
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CIFF’s strategy will target indicators of comprehensive impact, focussing on stunting and severe wasting as these impact people’s whole life course
Wasting is the most acute form of undernutrition, most closely linked to death
Stunting Is the measure most strongly linked to human capital (education, future income). Fighting stunting answers societal needs
NB: these indicators will be the ones we will measure success against © 2012 Emiliano Albensi/Albefotografiche.net, Courtesy of Photoshare
3. CIFF objective
Picking a battle: faces of malnutrition
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To achieve our objectives, we will prioritise support to the next generation of country success stories, combined with targeted global actions
* See slide 15 for country selection criteria
3. CIFF objective
5 Transformational country programmes at scale to support and document the next generation of success stories that will fuel the momentum and build evidence and knowledge about what works
Global targeted actions focused on: - data and knowledge, - innovation and - advocacy and accountability
Priority Geographies:BangladeshEthiopia, Indian State (TBD) + 2 African countries (TBD)*
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Our ambitious impact target is a 30% relative reduction in stunting in five priority countries
*The WHO standard indicator for stunting measuring prevalence in <5 year olds will be used but most of the interventions to prevent stunting will target the first 1,000 days of life as this is the “critical window of opportunity” after which limited catch-up growth is possible. (Lancet series, 2013)**Assuming an initial 40 % prevalence level***Starting from baseline of $1000GDP/cap
50% greater relative reduction than the projected impact of the Lancet 2013 package of interventions
What a doubling of per capita GDP might be expected to deliver***
3. CIFF objective
30% relative reduction in under-5 prevalence*
in 5 years, i.e.12 percentage points or 2.4 percentage points per year**
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…and one million additional Severe Acute Malnutrition cases successfully treated per year globally by 2020
• UNICEF reported recovery numbers in 2012 of 1.7 million • © 2012 Emiliano Albensi/Albefotografiche.net, Courtesy of Photoshare
• 60% more children successfully treated for Severe Acute Malnutrition than in 2012*
• Increase coverage of Community Management of Acute Malnutrition (CMAM) by 50% and ensure recovery rates above 75% (SPHERE standard minimum)
• Leverage combined service delivery, advocacy and cost reduction strategy to enable scale up in high burden Severe Acute Malnutrition countries
3. CIFF objective
1 million
Additional Severe Acute Malnutrition cases treated successfully per year globally by 2020
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CIFF’s STAR approach: making nutrition a top economic and development priority, supported by transformational programmes at scale in priority countries
Resource mobilisation& budgets
Institutions and
community
Data & Knowledge
Innovative products, services &
tools
Transformational programmes at scale
for a 30% stunting reduction and SAM treatment in priority
countries
Global actions
Leaders and
champions
4. CIFF’s “star”approach
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4. Country selection
Rationale for the selection of countries where CIFF will support transformational programmes at scale ($10-30m per year per country for 5-7 years to reach 2020 targets)
Significant burden: We excluded countries:
• With a too small burden
• Already well advanced in stunting reduction (prevalence <25%, annual reduction rate >2 percentage points)
A potential to become leaders in the nutrition space:
• At the country level: We analyzed the country leaders’ history on nutrition, the history of these countries in pioneering health sector innovations, and their likely regional influence
Ability to deliver : We analyzed:
• The country context (limited corruption index, high spending on health, percentage progress in health and sanitation making success more likely, political stability both in terms of people and institutions, potential for in-country scale up in terms of access and public health infrastructure at community level)
Role for CIFF: We analyzed:
• CIFF existing relationships (facilitating the rapid launch of collaborative initiatives)
• We only selected countries where CIFF would contribute significantly to a change in undernutrition as one of the lead donor, yet also leave sufficient “financial space” for other donors to follow
To maximise the impact of CIFF’s support, selected priority countries combine:
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At the centre of CIFF STAR’s approach, transformational programmes at scale will be country-tailored portfolio of projects, sharing common principles
• CIFF as one of the leading donors in the country, with funding of $10m-30/year for the next 5 years
• Aspiration to work with government and partners towards a 30% reduction in stunting by 2020• Focus on sustainability with a clear exit strategy for 2020. Programmes will be designed with
eventual scale up in mind in a cost-effective sustainable way with financing taken over by government, communities and businesses
• Prioritising high impact interventions for scale up, where these intersect with country priorities• Focus on a portfolio of projects for synergistic impact
• Focus on reducing costs and testing innovations• Working with partners using a diagonal approach and seeking to leverage government and
private resources • Focus on households as key agents for change and economic actors of nutrition
4. Country approach
• Working with government directly (supporting their programmes) or • in support of national priorities through other partners such as key
members of civil society• Working with businesses to support commercial solutions• Supporting R&D (by private or public actors)
at country levelInfluence on
entire country
Direct support to ~30% under-5 coverage by
CIFF
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Note: 1. This classification of interventions will be reviewed regularly as new evidence of impact come to light2. The need for specific interventions will vary depending on local epidemiology3. Gender will be considered during the intervention design, implementation and M&ESource: Lancet series 2013 and CIFF internal nutrition evidence assessment
*Not including health interventions
4. CIFF’s “star” approach - stunting
We need to make choices about interventions. We will focus on those with largest potential for impact in terms of under 5 stunting reduction (plus CMAM for SAM) based on local epidemiology and plans
Zinc for diarreah
Birth spacing
Vit. A suppl. childrenIron suppl. of children
Handwashing promotion
Homestead food production (dietary diversity)
Interventions to increase girls’
secondary schooling
Homestead food production
(animal sources)
Calcium suppl. in pregnancy
Antibiotics for pregnant ♀with bacteria in their
urineTobacco cessation in
pregnancy
Preventive zinc for children
Nutrient-dense complementary foods
Micronutrient suppl. in pregnancy (including
iron and folic acid)Appropriate
complementary feeding promotion
Antenatal care package
Platform type:
Community promoter package
Market transacted package
Campaigns
Breastfeeding promotion
Promotion of delayed age at first birth
Deworming
Psychosocial stimulation
Water quality interventions
Measles immunisation
Optional synergies given implementation platforms
Operational R&D
Malaria prevention In pregnancy
Balanced energy-protein
suppl. in pregnancy
Feasibility
Potential for impact on stunting reduction
Proven high impact
interventions
Proven low impact on
stunting
Proven effective
for a sub-group
“Must have” interventions for transformational programmes
Prevention of mother to child HIV transmission
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• In our review of interventions to reduce the burden of stunting, we could not identify evidence that immediate, exclusive, or continued breastfeeding positively impacts the prevalence of stunting
• However, we fully recognise that immediate, exclusive, and continued breastfeeding are essential nutrition actions to save lives and to accelerate cognitive and emotional development
• We will support efforts to improve breastfeeding practices as part of integrated Infant and Young Child Feeding programmes which also have a strong focus on complementary feeding
• We condemn violations of the International Code of Marketing of Breast-milk Substitutes. We would like to see better monitoring of the Code at country level
• We will continue to dialogue with all partners in an effort to reduce violations of the Code
CIFF strongly supports efforts to increase recommended breastfeeding practices
4. CIFF’s “star” approach - stunting
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CIFF will prioritise interventions with largest potential impact in terms of under-5 stunting and wasting*
*Prioritization of interventions will vary depending on local epidemiology.
Stunting
Wasting
4. Country approach
Antenatal care for women in pregnancy: Must-have interventions: Micronutrient supplementation (including iron and folic acid), malaria prevention, balanced energy-protein supplementation Operational R&D: Antibiotics for women with bacteria in their urine, calcium supplementation, tobacco cessationOptional synergistic programmes: Prevention of mother to child HIV transmission
Household behaviour change through community-based agentsMust-have interventions: appropriate complementary feeding promotion, birth spacing, interventions to increase girls’ secondary schooling (in partnership with education programmes), promotion of delayed age of first pregnancyOperational R&D: Homestead food production (animal sources)Optional synergistic programmes: Breastfeeding promotion, handwashing promotion
Business approaches for fortified infant and mother foodsMust-have interventions: nutrient-dense complementary foods
Health campaignsMust-have interventions: Measles immunisation Optional synergistic programmes: Deworming of pre-school children
Scale up of CMAM programs or set up of new programs
KPIsReduction of stunting burden in 5 years in whole country (CIFF zones of action + leverage)
Number of Severe Acute Malnutrition cases successfully treated per year by 2020
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CIFF will continue to invest in the scale-up of community management of acute malnutrition (CMAM)
• Treating children with deadly, yet curable, conditions like SAM alongside longer term preventative efforts will avert millions of deaths
• CIFF shares the longer term aspiration that no child fall into a SAM state in the first instance. We will seek opportunities to integrate SAM treatment into programmes that focus on prevention of undernutrition e.g. comprehensive stunting prevention programmes
• As a life threatening condition for which an effective cure is readily available at reasonable cost, SAM treatment should be provided by governments as an essential service on a long term basis
4. CIFF’s “star” approach - SAM
• 17 million children under-five suffer from severe acute malnutrition, but less than 10% are treated successfully and an estimated 1 million die each year
• Limited number of donors and funding
• Strong evidence on the effectiveness of SAM treatment within a community based management programme with high cost effectiveness – community management of acute malnutrition (CMAM)
• Integrating CMAM into an Integrated Community Case Management (ICCM) approach may be even more cost effective
There remains a significant need to save lives
There is strong evidence of effective treatment
There is a need to integrate treatment as essential public service
Treatment is needed alongside prevention
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To achieve our target of an additional 1 million children treated successfully for SAM every year by 2020, the number of admissions into CMAM programmes needs to increase by almost 60%. To do this our SAM strategy focuses on three key objectives designed to increase coverage of CMAM:
Increasing coverage of SAM treatment by mainstreaming CMAM as an essential health service must be included in our priority country approach and in the intervention package supported through the Catalytic Financing Facility.
A country approach in itself will not be sufficient to meet our ambitious target and we must also support efforts to scale up CMAM outside of these countries through cost reduction strategies. Although CMAM is cost effective, continued work on alternative formulations of ready-to-use therapeutic food, research and innovation on treatment regimen are needed
Where CMAM treatment is not currently acceptable, efforts will focus on supporting the development of an acceptable approach combined with targeted advocacy to support policy change and enable treatment scale up
4. CIFF’s “star” approach - SAM
Cost reduction will be the strongest single contributor to additional children treated successfully by our SAM strategy
CIFF’s SAM strategy:
Additional children successfully treated
Additional children successfully treated
Additional children successfully treated
Mainstreaming of CMAM as an essential health service
CMAM introduction in high burden countries
Cost Reduction
350,000
250,000
400,000
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Directly invest significant resources in interventions that do not impact stunting or SAM.
4. CIFF’s “star” approach – what we will not do
CIFF will not…
The driving force behind the choice of intervention is whether there is sufficient evidence that the intervention is efficacious and feasible in achieving our goals regardless of whether it is nutrition specific or nutrition sensitive. In particular, CIFF will not invest significant resources in fighting obesity, or in nutritional interventions unrelated to growth (e.g. vitamin A, iodine, etc.)
Finance a multitude of small programmes across different countries. CIFF will rather focus on delivering a comprehensive intervention package in a limited set of countries, with the aim of maximising their chances of success and supporting these countries in becoming global trail-blazers.
Work in isolation or duplicate what is already done by others in the focus countries
Enter into service delivery commitments alone, without co-funding from other donors and/or government/partner funds.
Success at scale can only be achieved through strong partnerships. If already covered by another entity, CIFF will collaborate with government agency or donor/partner and use its own resources only for other parts of the ideal package
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Goal in priority countries:Households and governments prioritise nutrition.
Goal at global level:Nutrition central to development dialogue. CIFF could support:
Leaders & champions, Institutions, Resources
4. Global & country actions
Formulation of persuasive case for nutrition by leaders and champions
Development and implementation of advocacy campaign for additional budget allocations
Set-up and evaluation citizen accountability mechanisms
Developed, costed and validated frameworks (policies/plans/coordination mechanisms)
Producing the analysis of fiscal space and financial flows to nutrition at national and sub-national levels
Awareness raising of need for behaviour change for good nutrition in communities
Establishing the human and economic case for nutrition through leaders and champions
Activation of inter-country networks to build global constituency
Development and implementation of advocacy campaign for N4G commitments to be met and increased
Set up of Catalytic Financing Facility
Strengthening regional institutions to deliver nutrition frameworks, policies and accountability mechanisms
Development and dissemination global accountability report
KPIs
20 new signatories to Nutrition for Growth by 2016
Nutrition budget increased by the equivalent of at least 3% of
government budget on health in three priority and at least five
selected non-priority geographies by 2020.
$2bn of additional commitments for nutrition by 2020
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Goal in priority countries: Improved data and knowledge to drive nutrition results. CIFF could support:
Goal at global level:Increased knowledge on unresolved nutrition issues. CIFF could support:
Building data & knowledge
Case studies of successful transformations of countries’ nutrition environments
Modelling tools to reshape programmes, e.g. establishing optimal lowest-cost bundle of locally available foods for pregnant women and young children
Research on critical programme questions and capacity development of local research institutions
Coverage measurement of progress and cost through locally tailored surveys ensuring quality assurance of collection and analysis
National information systems on nutrition including citizen led data
KPIs:
Key nutritional indicators are included and measured in regular
country-level surveys
Population coverage of stunting intervention package, including
coverage of CMAM
Publish and disseminate 25 papers on effective implementation
science through international forums
Existing Global tracking systems of inputs (resources) and outputs (intervention coverage)
Dissemination of national data and case studies to sub-region and global audiences, including data from experiential learning
Standardised M&E methodology to support planning programme implementation including data collection and analysis of key status and coverage indicators.
Efficacy studies/Proof of concept for stunting and SAM interventions with high potential
4. Global & country actions
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Goal in priority countries:Increased (cost-) effectiveness of nutrition interventions. CIFF could support:
Goal at global level:Increased (cost) effectiveness of products and delivery mechanisms. CIFF could support:
Supporting innovation in products, services & delivery strategy
4. Global & country actions
Diagnostics in priority countries on consumer preferences, existing markets and business environments for complementary foods and foods for PLW.
Local food businesses in creating new improved products for both young children and their mothers
Innovative ideas that emerge from the priority country diagnostics
Design and implementation of innovative tools in national nutrition programmes including use of technology to reinforce behaviour change
KPIs
Commercial solutions developed for nutrient-dense foods for children aged 6-24m
and pregnant and lactating women
Cost of commercially available RUTF reduced by at least 50%
from 2014 prices
Proof of concept for 5 new interventions, products or
delivery modes that on average reduce stunting by 2% each
R&D programmes focused on RUTF cost reduction and volume optimization and the development of balanced protein-energy supplements for pregnant women
Operational R&D opportunities that have potential to reduce stunting e.g. maternal calcium supplementation. The evidence will be reviewed and challenges and potential opportunities identified
A wholesale approach to building an innovation pipeline by investing in entities that self manages several proof of concepts/innovations
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Together, CIFF’s country and global activities will transform 5 countries and seek to accelerate global momentum for the elimination of malnutrition
5. Conclusion
CIFF Quantitative Targets
Scale up transformational nutrition programmes reaching millions of households
Reduce the prevalence of stunting by 30% (relative reduction) in five priority countries by 2020, relative to 2014
Successfully treat an additional one million children with Severe Acute Malnutrition per year by 2020, relative to 2013
Coverage increase of X key SUN interventions by [TBD]% in five selected non priority countries
Transform the political and institutional environment for nutrition
20 new signatories to Nutrition for Growth by 2016
Nutrition budget increased by the equivalent of at least 3% of government budget on health in three priority geographies and at least 5 selected non-priority countries (/geographies) by 2020, relative to 2013
$2bn of additional commitments for nutrition ( $1bn from CAFIN) by 2020, post Nutrition for Growth
Test new products and delivery strategies
Average cost of RUTF (price and/or volume) needed to treat one child with Severe Acute Malnutrition reduced by at least 50% by 2020, relative to 2013
Proof of concept established for at least 5 new interventions, products or delivery mechanisms that on average reduce stunting by an additional 2% each
Develop commercial solutions for nutrient-dense foods for children aged 6-24 months and for pregnant and lactating women leading to [TBD] million more children and [TBD] million more pregnant and lactating women consuming adequate fortified products
Document coverage, efficacy and deployment of nutrition interventions
Nutritional status indicators included and measured in regular country-level surveys, in CIFF priority countries
Coverage of stunting intervention package, plus coverage of CMAM, established and routinely measured in at least five high burden countries in addition to the five CIFF priority countries. Data from all ten countries shared publicly
Twenty five papers published and disseminated through international forums on effective implementation science and/or cost effectiveness of delivering stunting and/or SAM interventions through the platforms identified by the CIFF strategy and deriving from CIFF supported work
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Appendix: Glossary
Absolute reduction of XX percentage points
Arithmetic difference between two percentages. E.g., a reduction in prevalence from 40% to 30% equals to a reduction of 10 percentage points
Complementary feeding
“The introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to two years of age or beyond”* (WHO)
Leverage
In this presentation, resource leverage means bringing new resources or shifting the use of existing resources towards better use
Micronutrient
Micronutrients are essential vitamins and minerals that every human being needs – in small quantities – for good health. These essential vitamins and minerals include vitamin A, iodine, iron, folic acid and zinc.
Nutrition-sensitive interventions
Programs that address the underlying causes of undernutrition in complementary sectors (agriculture, health, social protection, early child development, education, water and sanitation, etc…)
Psychosocial stimulation
Refers to the extent that the environment (caregiver-child bond and home) provides the child with physical (adequate sensory experiences, play materials, opportunities to practice skills) and emotional (affection, communication, child appreciation,...) stimulation to facilitate his/her development
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Appendix: Glossary
Relative reduction by XX percent
Ratio expressed as a fraction of 100. E.g., a reduction in prevalence from 40% to 30% equals to a reduction of 25 percent
Severe acute malnutrition (SAM)
Severe acute malnutrition in 6-59 month old children is defined by a weight for height z-score that’s minus 3 standard deviations below the median WHO child growth standard or by a mid-upper-arm circumference less than 115 mm, with or without nutritional oedema*
Stunting
Stunting reflects chronic undernutrition during the most critical periods of growth and development in early life. Moderate stunting is defined as height-for-age Z score (HAZ) between -2 and -3 standard deviations from the median of the WHO Child Growth Standards and severe stunting is HAZ<-3.
Wasting
Wasting reflects acute undernutrition. Moderate wasting is defined as weight-for-height Z score (WHZ) between -2 and -3 standard deviations from the median of the WHO Child Growth Standards, severe wasting is WHZ<-3
UNICEF, Micronutrient initiative, WHOPhotos from previous slide: (1) © Farrah Mateen, Courtesy of Photoshare, (2) © Dr. Steve Vosti , (3) © CIFF
Sources:
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