SOMALI NUTRITION STRATEGY 2011 – 2013 · Ali Mohamd Esese OIP A/rashid Gabobe Esse MoH Khadro...
Transcript of SOMALI NUTRITION STRATEGY 2011 – 2013 · Ali Mohamd Esese OIP A/rashid Gabobe Esse MoH Khadro...
SOMALI NUTRITION STRATEGY
2011 – 2013
Towards the
Millennium Development Goals
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© World Health Organization/UNICEF/WFP/FAO/FSNAU 2010All rights reserved. The designation employed and the presentation of the material in this report including tables and maps, do not imply the expression of any opinion whatsoever on the part of the World Health Organization, UNICEF, WFP and FAO/FSNAU concerning the legal status of any country, territory, city or area or of authorities or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent border lines for which there may not yet be full agreement. The mention of specific companies or suppliers or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization, UNICEF, WFP or FAO/FSNAU in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization, UNICEF, WFP and FAO/FSNAU do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.
This publication may be reproduced free of charge in any format or medium, provided that it is reproduced accurately, that the original contributors are given due credit, and that it is not used in a misleading context.
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ForewordGood nutrition is one of the key foundations for the development of a healthy, productive population. Well nourished people are less likely to become ill or die, and are more productive and better able to learn. Achieving good nutrition, particularly among women and children, is associated with important short and long term health, educational and economic benefits.
Situational analysis of data from Somalia over the last decade indicates that undernutrition is a significant and enduring public health problem and a major factor in the failure to meet MDGs on hunger, child health, maternal mortality, gender equality and education. Rates of acute and chronic malnutrition have remained persistently high throughout Somaliland, Puntland and South Central Somalia, with some variation by zone and livelihood system.
Ongoing conflict, displacement, breakdown in social and public services coupled with recurrent droughts and flooding have significantly affected food security and livelihoods and therefore nutritional status. However, there is a growing body of evidence that other underlying causes also contribute significantly to high and persistent undernutrition. These factors include: chronic poor dietary diversity, inadequate infant, young child and maternal feeding practices, poor hygiene practices, water and sanitation, poor health seeking behaviours and low access to quality health services and education and gender inequalities. The persistence of undernutrition, even in years of relative stability and good harvest, adds further weight to the importance of these multiple underlying causes which by their nature cut across traditional sectors. With increasing understanding of the causes and their complexity, the challenge now is to strengthen efforts to address them through an integrated multi-agency, multi-sector response.
The objective of the work carried out by authorities, donors, UN agencies and local and international implementing partners was to develop a joint framework for action to improve the nutritional status of the Somali population, thereby contributing to an overall improvement in their survival, growth and development.
The activities detailed in this strategy aim to respond to the challenges raised above and focus interventions to achieve 6 priority outcomes that will lead to accomplishment of the overall goal: i) improved provision of quality services for the management of acute malnutrition; ii) sustained quality nutritional surveillance and analysis of nutrition information to inform appropriate and rapid responses; iii) improved knowledge, attitudes and practices regarding infant, young child and maternal nutrition; iv) improved availability, accessibility and coverage of micronutrients and de-worming; v) increased redress of underlying negative practices through awareness and commitment to effective action across other sectors and finally vi) improved capacity and means in country to make effective nutrition responses.
The development of the strategy has been based on a number of guiding principles. Primarily the strategy recognises the basic human right to adequate food and health and freedom from malnutrition and disease. It respects the humanitarian principle of ‘do no harm’ such that its’ implementation should not exacerbate or worsen the situation.
A key guiding principle is recognition of the specific context and challenges of implementation in Somaliland, Puntland and South Central Somalia. The multi-sectoral responses identified are based on an understanding of the specific political, economic, social and cultural factors that determine nutritional status. The interventions detailed in the action plan reflect universally accepted best practice and evidence-based programming. However, not all interventions proven effective in addressing malnutrition (The Lancet series on Maternal and Child Undernutrition) are
iv feasible in the Somali context where the volatile environment, low access, weak infrastructure and legislative framework are major constraints. Therefore, the strategy aims to prioritise and adapt what is proven effective, with what is viable in the context.
Finally, mindful of the importance of using limited resources to greatest efficiency, the strategy focuses on investing in the areas most likely to achieve maximum impact. As such, interventions are targeted at pregnant mothers and children up to the age of two years as the critical window of opportunity for reducing undernutrition and its adverse effects. (Lancet series on Maternal and Child Undernutrition). Furthermore, many of the interventions identified in this strategy correspond to those acknowledged by the Copenhagen Consensus 2008 as the most cost effective interventions for global development.
This strategy has been developed through strong interagency collaboration, with input and endorsement from Somali authorities. It is hoped the strength of this collaboration prevails throughout the implementation phase, in pursuit of a common overall goal to improve the growth, survival and development of the Somali people. The strategy provides the way forward for stronger partnerships within the nutrition sector and between nutrition and other sectors and ministries for coherent action to achieve this shared goal through improving the nutritional status of the population.
Mark Bowden UN Resident and Humanitarian Coordinator for Somalia
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This Somali Nutrition Strategy has been developed in response to increasing evidence and awareness that the persistently high rates of malnutrition in Somalia are related to multiple underlying causes that need to be addressed through a more holistic and longer term approach.
The process of developing the strategy has been a consultative. Initially, a task force of technical representatives from key UN agencies and local and international NGOs was formed to work on a draft. A results based, action orientated approach was adopted, using the logical framework to identify and define the overall goal, outcomes, outputs and activities of the strategic plan. The outcomes identified reflect the priorities identified in the situational analysis and analysis of the strengths, weakness, opportunities and threats of current nutrition programming.
The draft prepared by the technical interagency task force was then shared with nutrition and other relevant clusters and sector working groups, and the UN County Team at Nairobi level. A key stage of the process was sharing the draft with Somaliland, Puntland and TFG authorities and local actors for their input and obtaining their endorsement. Thus the final document represents a consensus on the combined inputs of all relevant stakeholders.
Preface
vii AcknowledgementsAs outlined above, the process of developing this strategy has been a collaborative one between UN agencies, local and international NGOs, line ministries of Somaliland, Puntland and TFG authorities. We would like to acknowledge the contributions of staff from all these various agencies.
In particular, special thanks go to members of the technical Task Force for their experience, knowledge and time devoted to developing the strategy:
Dr Anthony Abura World Vision International Fitsum Assefa Nutrition Project Co-ordinator, UNICEF SomaliaSuzanne Brinkman Nutrition Coordinator, Save the Children UK Anne Bush Consultant Public Health Nutritionist, WHO SomaliaAhono Busili Deputy Nutrition Technical Manager, UNFAO/FSNAUAbdullahi Mohamed Diriye Development Initiative Access Link (DIAL)Erin McCloskey Nutrition Advisor, Somalia, Concern WorldwideAbdi Moge Mohammed Somalia Aid Foundations (SAF)Grainne Moloney Nutrition Technical Manager, UNFAO/FSNAUAnne-Sophie Porche Nutrition Cluster Coordinator, UNICEF SSCMarc-Andre Prost Nutrition Officer, WFP SomaliaUnni Silkoset Nutrition Specialist, UNICEF Somalia CSZKeith Ursel Head of Programme, WFP Somalia
Thanks also go to other key contributors:Fatuma Abdirahman CTC Project Manager Oxfam NovibAusten Davis Chief, Accelerated Child Survival and Development
Programme, UNICEF Somalia Dr Marthe M. Everard Representative WHO Somalia Peter Hailey Regional Nutrition Specialist, UNICEF EASROAbdirizakov Osman Nutrition Officer, UNICEF Somalia CSZ Dr Humayan Rizwan Technical Officer (PHC) WHO Somalia Osborne Sibande Acting Nutrition Officer WFP SomaliaRandhir Singh Relief InternationalMarijka van Klinken Nutrition Project Officer (Intern) UNFAO/FSNAU
Members of the IASC Nutrition Cluster Members of IASC WASH, health, food aid and agriculture/livelihoods clusters
Somaliland contributorsAbdillah Seleman Abdi MoADr Mohamed Saleban Adan MoADr. Hassan Abdillahi Ahemd MoH/LFoosiya Ahmed MoH/LAmina Barkahod MoH/LRahma Mohamed Cabdi MoH/LAbdirahman Deria AGAADAbdi Dahir Elmi WHOMohamed Sulyman Elmi MoCFatuma Ali Farah MoH/L
Mumtoos Dahir Farah SIAMAFatuma Ali Farax MoH/LSadik MohamoudGahyer Muslim Aid UKHassan Haileh MoH/LAhmed Hassan ANPPCANDr.Abdi Hussein MoH/LDr. Mohamed Idan MoH/LDr. Faysal Ismail MoH/LDr. Saynab Mohamed Ismail MoH/L
viii Dr. Ahmed Mohamed Jama MoH/LTheresa Loro WFPKadair Abdiillah M MerlinJane Maina WVINeura Ibrahim Mohamed MoH/LDr. Khadar Mohamed MoH/LKoos Mohamed WFPZivai Murira UNICEFGeorge Mutwiri Medair
Dr. Mohamed Osman Nur MoH/LMohamed Sheikh UNICEFDr. Ali Shiekh MoH/LNorman Sitali MSF HollandMohamed Osman Yabe MoH/LDr. Abdi Kin Ying WHOZainab Maxed Yusuf MoFAsia Osman WHO
Puntland contributorsAbi Abdallah Warsame, Minister of HealthHamdi .Y. Abdullahi WFPMohamud Abdullahi WFPHamdi Abdullahi Ali SCUKJama Mohamed Daar SCUKAbdikarim Husen Duale FSNAUMohamed Ahmed Duale SOMDA Said Abdullahi Duale MoHAli Mohamd Esese OIPA/rashid Gabobe Esse MoHKhadro Mohamud Esse MoHAbdirahman Omar Fahad MoHAhmed Abdirahman Fahiye MoHMohamed Ali Fantole SDRADr Abdirazak Hirsi MoHMohamed Jama Hirsi MoHAbdinasir Sheikh Ibrahim MoHBashir Ali Ismail GDAHodan Mire Ismail UNICEF
Mukhtar Mohamed Jama MoHNaimo Mukhtar Moalim RPSAamina Abdi Mohamed Ein MCHNAnisa Ali Mohamed MoHDr Dahir Aadan Mohamed WHOFardowsa Ahmed Mohamed MoHMohamed Hared Mohamed SDROSaid A/qadir Mohamed Muslim AidSirad Aadan Mohamed SRCSAli Hassan Mohemed WHOMohamed Abduqadir Mulah MoHZivai Murira UNICEFAbdirahman Yusuf Muse UNICEFMohamed Abdulkadir Nor BIOFITHawa Yusuf Osman MoHLayla Said LQCDr Maymun Farah Samatar PMWDOHassan Abdi Shire MoHSaid Mohamed Warabe MoHMohamed Said Yusuf MoPIC
TFG contributorsDr Adan Haji Ibrahim Daud: Minister of HealthDr Abdi Awad: advisor to TFG MoH Dr Lul Mohamed Mohamed: Paediatrician in Benadir Hospital Abdinasir Hagi Mohamed: Director of Disaster and Risk Management Dept, Ministry of Humanitarian Affairs
Other contributorsDr Anna Verster, Nutrition Advisor to WHO and Senior Advisor on Food Fortification, who undertook preliminary work on developing the strategy
Anne Bush, Consultant Public Health Nutritionist WHO/UNICEF, who led the multi-agency task force and compiled the strategy document.
Thanks also go to FSNAU/FAO for their assistance in the design of the document and to WFP Somalia office for funding the printing of the final document. Also to WHO and UNICEF Somalia who contributed to the funding of the process, including the consultancy costs.
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AcronymsAYCS Accelerated Young Child SurvivalBCC Behaviour Change CommunicationCAP Consolidated Appeal ProcessCBI Community Based InitiativesCHD Child Health DayCMAM Community-based Management of Acute MalnutritionCTC Community-based Therapeutic CareEPHS Essential Package of Health ServicesFAO Food and Agriculture OrganisationFEWSNET Famine Early Warning Systems NetworkFSNAU Food Security and Analysis Unit – Somalia GAM Global Acute MalnutritionGAVI Global Alliance for Vaccines and ImmunisationHAZ Height for Age Z-scoreHMIS Health Management Information SystemHSS Health System StrengtheningIBFAN International Baby Food Action NetworkIDP Internally Displaced PopulationINGO International Non Governmental OrganisationIYCF Infant Young Child FeedingKAPS Knowledge, Attitudes and Practices Survey LNGO Local Non Governmental OrganisationMAM Management of Acute MalnutritionMCH Maternal Child Health MDG Millennium Development GoalsMICS Multi-Indicator Cluster SurveyMI Micronutrient InitiativesMoH Ministry of HealthNEZ North East ZoneNGO Non Governmental OrganisationNWZ North West ZoneOTP Out patient Therapeutic feeding ProgrammeRDP Reconstruction and Development Plan SAM Severe Acute Malnutrition SC Stabilisation CentreSFP Supplementary Feeding ProgrammeSCZ South Central ZoneUNICEF United Nations Children’s FundUNTP United Nations Transition PlanWABA World Alliance for Breast Feeding ActionWASH Water and Sanitation HygieneWFP World Food ProgrammeWHO World Health OrganisationWHZ Weight for Height Z-Score
x Table of ContentsForeword iiiPreface viAcknowledgements viiAcronyms ixExecutive Summary 1
1. Background 31.1 Nutrition situation 31.2 Determinants of malnutrition 41.3 Nutrition interventions 5
2. Justification, Scope and Guiding Principles 82.1 Justification 8
2.2 Scope 82.3 Guiding principles 8
3. Goals, outcomes, outputs 104. Implementation 13
4.1 Opportunities 134.2 Partnerships 144.3 Zonal differences 154.4 Formative research 164.5 Technical support 164.6 Behaviour Change Communication 16
5. Monitoring 17
AnnexesAnnex 1. Logical framework - Results based matrix 19Annex 2. Situational analysis 42Annex 3. Justification of outcomes and key approaches adopted in this strategy 60 Annex 4. Proven effective interventions identified by Lancet series on Maternal and Child Undernutrition 65Annex 5. Copenhagen Consensus 2008 66Annex 6. How malnutrition affects achievement of MDGS 67 Key References 68
List of Figures Figure 1. Seasonal trends in national median rates of acute malnutrition 2001-2009 3Figure 2. Annual national median stunting rates 2001-2009 4Figure 3. Median rates of wasting, stunting and underweight by Zone 2001-2008 4Figure 4. Prevalence of anaemia and vitamin A deficiency amongst women and children 2009 4Figure 5. Prevalence of some key determinants of malnutrition in Somalia 2009 5Figure 6. Trends in wasting, stunting and underweight by livelihood group, 2001-2008 44Figure 7. Malnutrition rates by zone 2009, according to National Micronutrient and Anthropometric Nutrition Survey, Somalia 2009 45Figure 8. UNICEF Conceptual model of causes of malnutrition 47Figure 9. Breast feeding initiation 49Figure 10. Age Specific fertility rates by urban-rural residence, Somalia 2006 50Figure 11. Immunisation coverage among children under five years, 2009 51
MapMap 1. Map of current nutrition situation and interventions as of 18th March 2010 7
List of TablesTable 1. SWOT analysis of current nutrition interventions in Somalia 56Table 2. Existing programmes presenting opportunities for the integration and strengthening of nutrition activities 57
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Executive SummaryMalnutrition in Somalia is a huge public health problem, negatively affecting growth, development and survival of the population. Situational analysis shows a long term nutrition crisis characterised by persistently high rates of acute and chronic malnutrition throughout the country with some variation by zone and livelihood system. This situation reflects nearly two decades of armed conflict and insecurity, with breakdown in social and public services coupled with recurrent droughts and flooding seriously affecting food security and livelihoods. In response to the alarming rates of acute malnutrition, nutrition programming coordinated by the Nutrition Cluster, has been primarily focussed on the immediate needs of saving lives through the management of acute malnutrition, based on seasonal assessments of food security and nutrition surveillance data primarily by FSNAU.
However, surveillance data shows that even in years of improved food production and relative stability, rates of acute and chronic malnutrition remain high in certain regions indicating other underlying causes play a significant role. Evidence shows that sub-optimal infant, young child and maternal feeding and care practices, low dietary diversity, poor hygiene, water and sanitation, high morbidity coupled with inadequate access to health care are key determinants of the problem. To address these multi-factorial and overlapping causes, a holistic package of interventions with multi-sector collaboration is required. This strategy has been developed via a consultative approach between UN agencies, local and international NGOs and the national and regional health authorities to provide an agreed upon framework for action to meet this need for a shift to a more holistic approach.
The results-based strategy provides a detailed action plan to guide prioritisation of interventions in face of limited resources, project implementation and resource mobilisation. Based on the situational analysis, review of best practices and proven effective interventions feasible in the challenging context of Somalia, the following goal and outcomes for the strategy have been established.
Overall of the strategy is: To contribute to improved survival and development of Somali people through enhanced nutritional status.
This will be accomplished through the achievement of the following outcomes: Outcome 1: Improved access to and utilisation of quality services for the management of
malnutrition in women and childrenOutcome 2: Sustained availability of timely and quality nutrition information and operational
research into effective responses to the causes of undernutrition Outcome 3: Increased appropriate knowledge, attitudes and practices regarding infant, young
child and maternal nutritionOutcome 4: Improved availability and coverage of micronutrients and de-worming interventions
to the population Outcome 5: Improved mainstreaming of nutrition as a key component of health and other
relevant sectors Outcome 6: Improved capacity and means in country to deliver essential nutrition services
The outcomes will be achieved by conducting defined activities that will produce key outputs. Implementation of the strategy will be guided by the overarching principle of improving partnerships between all stakeholders – local and national authorities, donors, UN agencies, local and international NGOS, local community and the private sector – and increased collaboration
2 between sectors. While the main entry point will be through the strengthening of existing structures and services, the strategy also explores new avenues for the provision of services, for example, the fortification of cereal flours.
Due to constraints to rapid scale up of interventions (restrictions in access, logistic, human and financial resources) a phased approach has been adopted. Activities for the first year (phase 1) are focused on the adaption and standardisation of tools, training and strengthening of structures and mechanisms in preparation for delivery of interventions in the subsequent years (Phase 2). The strategy is consistent with the United Nations Transition Plan (UNTP) for Somalia 2008-09 and has been included in the Reconstruction and Development Plan (RDP) for the next three years.
The three year term of the strategy is too short to measure significant changes in nutritional status and mortality as outcome indicators. Instead, the results matrix gives details of the output and outcome (impact) and activity (process) indicators and their source of verification against which effectiveness of the strategy will be measured. The progress made in the implementation of the strategy will be reviewed and updated on an annual basis. The inter-agency review process will be led by the Ministries of Health in collaboration with technical support from the Health Sector Committee and undertaken with all stakeholders including regional line ministries. Annual review will be timed to take place prior to the Consolidated Appeal Process (CAP) so that findings can help inform and identify funding priorities.
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Since the collapse of central government in 1991 and the resulting civil war, there have been many efforts to restore a central government in Somalia without sustained success. In 1991, the North west zone (NWZ) declared the independent state of Somaliland, with its governing administration in the capital Hargesia. The North east Zone (NEZ) declared itself as the autonomous region of Puntland in 1998. Although governed by its administration in its capital Garowe, it pledges to participate in any Somali reconciliation and reconstruction process that should occur. In South Central Somalia political conflict and violence continue to prevail, despite attempts to establish and support a central governing entity.
A detailed situational analysis of the nutrition situation in country, determinants of malnutrition and current nutrition interventions, strengths, weaknesses, opportunities and threats can be found in annex 2. In brief, eighteen years of war and insecurity have had devastating effects on the nutrition and health status of the people of Somalia, which was already precarious even before. The combination of conflict, insecurity, mass displacement, recurrent droughts and flooding and extreme poverty, coupled with very low basic social service coverage, has seriously affected food security and livelihoods and greatly increased vulnerability to disease and malnutrition. The MDG health-related indicators are among the worst in the world. Life expectancy is 45 years. One child in every twelve dies before the age of one year while one child in seven dies before the age of five.
1.1 Nutrition situationRates of acute malnutrition and chronic malnutrition are alarming throughout the country with some variations by zone and livelihood system. The most recent assessment from FSNAU Post Deyr ‘09/10 found a national median global acute malnutrition (WHZ < -2 SD) rate of 16%, severe acute malnutrition (WHZ < -3 SD) rate of 4.2%, based on WHO growth standards (2006). These rates correspond to an estimated 240,0001 children acutely malnourished of which 63,000 children are suffering severe acute malnutrition. Thus one in six children aged 6 to 59 months are acutely malnourished and one in twenty two, severely malnourished. In addition, according to the previous FSNAU seasonal assessment post Gu 2009, 84,000 pregnant and lactating women are estimated to be acutely malnourished.
Preliminary results from FSNAU meta analysis of data from 2001 to 2009 highlight the chronic nature of this alarming situation. The results show that over this period, median rates of global acute malnutrition have remained at Serious (10 to <15%) or Critical (15 to <20%) levels (WHO Classification 2000) throughout (Figure 1), with a national median rate of 16%.
Furthermore, annual national median rates of stunting were above 20% ie at serious level throughout the period 2001 to 2009, according to WHO classification (2000), as shown in figure 2.
1 Figures based on population figures from the UNDP 2005 settlement survey are used as the standard reference for Somalia
BACKGROUND1
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Figure 1: Seasonal trends in national median rates acute malnutrition 2001-2009 - Source FSNAU
4 Preliminary results of the meta-analysis also highlight how the situation has been consistently worse in South Central Somalia than Puntland or Somaliland. In South Central Somalia, median rates of stunting were found to be 29.7% and wasting 18%; this compares to 20% stunting and 17% wasting for Puntland and 18% stunting and 13% wasting for Somaliland (see figure 3). This reflects the devastating effect of chronic political conflict and insecurity in South Central Somalia in particular.
Rates of malnutrition also vary according to livelihood system. Briefly, preliminary results of the FSNAU meta analysis of data 2001-2008 revealed that riverine and agro-pastoralist groups had the highest median rate of wasting, stunting and underweight suggesting a higher nutritional vulnerability to shocks – floods, drought, displacement, disease outbreak. Rates of malnutrition among the urban population tended to be lower, reflecting better access to a diversified diet and to public services including health.
The recent National Micronutrient and Anthropometric Nutrition survey conducted between March and August 2009 in all three zones, has highlighted micronutrient malnutrition is a significant public health problem throughout Somalia. The prevalence of both nutritional anaemia and vitamin A deficiency among women and children of all age groups was found to be above WHO thresholds for classifying a severe situation in each of the 3 zones (see figure 4).
1.2 Determinants of malnutrition Malnutrition results from a complex set of factors and not one simple cause. The UNICEF conceptual model of causes of malnutrition (page 16) provides a useful framework for the discussion of the causes of malnutrition in Somalia. The volatile political situation and civil unrest have led to a chronic and continuing humanitarian crisis that is at the root of the high prevalence of malnutrition in Somalia. Somalia is also prone to drought and floods. Many of the environmental and man made shocks have been multiple and recurrent, over stretching families’ coping mechanisms resulting in inadequate access to and availability of food at household level.
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Source FSNAU data Micronutrient Study
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Figure 2: Annual National Median Stunting rates 2001-2009
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5 However, even in years of relative stability and improved food production, the malnutrition rates in some regions of Somalia have been consistently high, pointing to the important role of other underlying causes. These include sub optimal infant, young child and maternal feeding and care practises as documented by the National Micronutrient and Anthropometric Nutrition Survey 2009, KAPS 2007 and MICS 2006 results. Morbidity is high while access to and utilisation of quality health services is limited (KAPS 2007 and MICS 2006). The water and sanitation situation is poor. Feeding, care and hygiene practices are inadequate not only due to lack of public services but also due to cultural practices and beliefs. Figure 5 summarises data from the micronutrient survey indicating the low coverage of some of these key determinants. Each is discussed in more detail in the situational analysis attached (annex 2).
1.3 Nutrition interventionsDue to inadequate governance structures in parts of Somalia, nutrition response programming is mainly undertaken by UN, international and national NGOs. Nutrition interventions are primarily focussed on responding to alarming rates of acute malnutrition throughout the country. Food security and nutrition surveillance and early warning reports (FSNAU, FEWSNET, WFP) are key activities providing quality information and analysis for the targeting of appropriate and timely responses to changing needs in country. Outpatient therapeutic feeding programmes (OTPs) for the management of severe acute malnutrition are being implemented across Somalia by international NGOs and UNICEF in partnership with local NGOs, according to operational guidelines that take into account the challenging environment, reduced supervision and limited monitoring.
Targeted supplementary feeding programmes (SFPs) for the management of moderately malnourished under-fives and pregnant and lactating women are being implemented by WFP through around 40 local and international NGOs. The current caseload is around 70,000 beneficiaries, of whom approximately 80% are under-fives and 20% pregnant and lactating women. Map 1 shows the current nutrition situation and interventions based on latest reports.
Activities for the prevention of moderate acute malnutrition include the provision of fortified supplementary food by WFP to all children under-two and pregnant and lactating women, through UNICEF-supported MCH clinics at selected sites in Puntland and Somaliland. Currently 35 clinics are supported. In addition, in 2009, UNICEF launched a new initiative for the prevention of malnutrition, targeting 100,000 children aged 6-36 months with blanket distribution of ready-to-use food (Plumpy Doz) every two months in areas showing the highest malnutrition rates.
Baidoa MCH, UNICEF Somalia, CK Minihane
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!Prevalence of diarrhoea 0-59 mths
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%Immunisation coverage DPT 6-23 months
6Introduction of solids, semi solids, soft food 6-8mths
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3Early initiation of breastfeeding (within 1st hour)
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Figure 5: Prevalence of indicators of some key determinants of malnutrition in Somalia
Source: Micronutrient Survey2009
6 Furthermore WFP is providing food assistance to vulnerable groups through institutional feeding and school feeding to around 90,000 beneficiaries. WFP also provides a general food ration consisting of cereals, CSB, sugar, fortified oil and iodised salt when available, to the rural population affected by the humanitarian crisis, the urban poor and IDPs. In 2009 this food assistance covered around 3 to 3.5 million people a month – almost half the population – on the basis of FSNAU seasonal assessments.
Nutrition interventions delivered through health campaigns include vitamin A distribution, deworming and nutritional screening during bi annual Child Health Days. Furthermore, nutrition interventions are delivered through the 3 levels of the health system – health posts, MCH Clinics and hospitals. Coverage and quality is currently limited due to overall weaknesses of the public health system.
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Map 1: Somalia - Nutrition Treatment Interventions in Somalia as of November 2010
2. JUSTIFICATION, SCOPE & GUIDING PRINCIPLESJUSTIFICATION, SCOPE & GUIDING PRINCIPLES2
2.1 Justification
As described above, Somalia faces multiple challenges - not least conflict, drought, flooding, inadequate and inequitable social and public services and massive population displacement - but persistently high levels of malnutrition are undermining the survival, growth and development of the population. Rates of acute and chronic malnutrition have consistently exceeded emergency thresholds in some areas for more than 10 years now. Due to the scale of the humanitarian situation in Somalia and the alarmingly high rates of acute malnutrition, the vast majority of the nutrition interventions are focussed on the management of acute malnutrition. This remains a key priority to prevent associated excess morbidity and mortality.
However, the situational analysis shows that in some regions rates of chronic and acute malnutrition remain high even outside of times of crisis, with multi factorial underlying causes. These underlying causes include: sub optimal infant, young child and maternal feeding and care practices, poor dietary diversity, inadequate water and sanitation and high morbidity coupled with poor access to and utilisation of health services. These multiple and overlapping determinants of malnutrition in Somalia require a holistic package of interventions delivered through a multi sectoral channels to address the huge public health problem. The range of stakeholders and the variety of approaches and projects with a nutrition goal or outcome mean a coordinated approach is necessary. The response also requires longer term planning, funding and programming. This strategy therefore has been developed to provide an agreed upon framework for action to respond to this need for a shift in approach, whilst continuing to improve the quality of management of acute malnutrition.
2.2 Scope
This strategy provides a tool to support co-ordinated action to improve and expand quality nutrition programming in Somalia in a phased approach over the next three years. It is based on a logical framework and is therefore rooted in actions that if conducted produce results that ultimately mean outcomes are accomplished and the overall development goal is achieved. It is intended as an advocacy document for UN agencies and partners to donors. The results-based approach provides an action plan which guides the prioritisation of interventions in a situation of limited resources, project implementation and capacity building in the relevant areas, and resource mobilisation. It identifies opportunities and existing structures that provide entry points for developing and integrating interventions. It aims to encourage the development of partnerships between all relevant stakeholders and facilitate cross sector initiatives to address the multi-factorial direct and underlying causes of malnutrition, whilst recognising the challenges of implementation in Somalia
As malnutrition is one of the most important constraints to achieving MDGs, these coordinated efforts will assist Somalia in making more meaningful progress towards attaining its MDGs. In particular, those more directly affected by improving malnutrition: goal 1 on reducing hunger, and goals 4 and 5 on the reduction of child and maternal mortality (see Annex 6).
2.3 Guiding Principles
This implementation of this strategy will be guided by the following principles:- Recognition of the basic human right to adequate food and health, for all people to have access to
safe and nutritious diets to be free from malnutrition and related disorders.
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- Recognition of the multiple and overlapping causes of malnutrition that require a longer term, inter-sectoral strategy and that reflect an understanding of the political, economic, social and cultural factors that determine nutritional status
- Recognition of the need to build local capacity and resources to respond and promote local ownership
- Recognition of the context of the specific situation in Somalia where access is limited, using existing services and structures as entry points for enhanced interventions.
- Recognition that the critical window of opportunity for reducing undernutrition and its adverse effects is the period from pregnancy to 24 months of age (Lancet series on Maternal and Child undernutrition). Interventions after 24 months are much less likely to improve nutritional status and do not reverse earlier damage.
- Reflection of universally accepted best practice and evidence based interventions. The Lancet series on Maternal and Child undernutrition provides evidence on interventions that are proven effective in addressing malnutrition (see annex 4). Not all are feasible in the challenging context of Somalia, requiring a less volatile environment, better access, a stronger public health system, legislative framework and longer term funding. The strategy prioritises what is proven effective with what is feasible and can be adapted to the Somali context. It is also important to note that many of the interventions identified in this strategy correspond to those acknowledged by the Copenhagen Consensus 2008 as the most cost effective interventions for global development (see Annex 5)
- Recognition of the principle of ‘Do no harm’. Respecting this, implementation of strategy should not exacerbate or worsen the situation.
The goal, outcomes, outputs and activities of the strategy have been identified using a logical framework approach. They are based on the priorities, strengths, weaknesses, opportunities and threats identified in the situational analysis and reflect proven effective interventions that are feasible in the challenging context of Somalia. Justification of each outcome and the key approaches adopted are described in annex 6.
The overall development goal of this strategy is to contribute to improved survival and development of Somali people through enhanced nutritional statusThis contribution will be achieved through the accomplishment of the following outcomes (expected benefits to the population) which in turn will be realised by the achievement of the specified outputs through conducting the defined activities.
GOAL, OUTCOMES & OUTPUTS 3
Outputs: 1.1 Quality services for the management of acute
malnutrition are enhanced and expanded
1.2 Quality services for the treatment of micronutrient deficiencies are enhanced and expanded
1.3 Food based interventions for the prevention of undernutrition in identified high risk populations are enhanced and expanded
1.4 Utilisation of available services for the prevention and treatment of acute and chronic malnutrition is increased
Outputs:2.1 Quality nutritional surveillance, monitoring
and evaluation is conducted and reviewed on a timely basis to inform the targeting of vulnerable populations with appropriate responses
2.2 Operational research to identify effective programmes to address the causes of undernutrition is conducted, according to an agreed upon set of priorities and plan of action, and is used as evidence base for long term strategic planning.
Child receives ‘Plumpynut’ from father, Concern Worldwide
Measuring height during a nutrition survey, FSNAU
Outcome 2: Sustained availability of timely and quality nutrition information and operational research into effective responses to address the causes of undernutrition
Outcome 1: Improved access to and utilisation of quality services for the management of malnutrition in malnourished women and children
11
Outputs: 3.1 Improved rates of early initiation and exclusive
breastfeeding practices
3.2 Improved rates of optimal complementary feeding practices
3.3 Local availability and consumption patterns of nutrient dense foods are better understood and this knowledge-base is used to promote increased intake of energy, protein and micronutrient-rich foods
3.4 Common practices that inhibit micronutrient absorption e.g. tea consumption are better understood and addressed
3.5 Improved access to nutrition education and counselling for pregnant and lactating women through health services and community based structures
Outputs:4.1 Increased availability of fortified food
4.2 Improved access to and utilisation of micronutrient supplements and fortified supplementary food by vulnerable groups through health services and novel community based delivery strategies
4.3 Increased coverage of de-worming through population-based delivery mechanisms: a) Child Health Days, b) schools, c) MCH services and d) nutrition programmes
Outputs:5.1 Nutrition is effectively incorporated into
the policies, strategies, activities, delivery mechanisms and outcomes of health sector
5.2 Nutrition is integrated into the policies, strategies, activities, delivery mechanisms and outcomes of relevant sectors (WASH, agriculture/livelihoods, education, food aid)
Mother breastfeeding child at Baidoa MCH, UNICEF Somalia, CK Minihane
Child receives Vitamin A supplementation at CHD in Hargeisa, UNICEF Somalia, Denise Shepherd
Johnson
Promotion of handwashing, DHK Mogadishu, SAACID/WFP
Outcome 3: Increased appropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition
Outcome 4: Improved availability and coverage of micronutrients and de-worming interventions to the population
Outcome 5: Improved mainstreaming of nutrition as a key component of health and other relevant sectors
12
Outputs:6.1 A two year nutrition sector capacity
development strategy and plan of action is developed by the end of 2011
6.2 Capacity development strategy and training activities are implemented according to plan of action
6.3 Regional training and mentoring cells are
formed by the end of 2011.
6.4 Internationally recognised training guidelines and protocols are adapted to the Somali context
6.5 An enabling environment for all stakeholders to implement quality nutrition programmes is created and sustained, in collaboration with local authorities
Nutrition training, Save the Children in Somalia/Somaliland
Outcome 6: Improved capacity and means in country to deliver essential nutrition services
13
The logical framework defining goal, outcomes, outputs and activities and associated indicators for monitoring progress is included in annex 1. In addition, a results-based matrix detailing the activities, responsible agencies and time frame for action will be developed. Due to constraints to rapid scale up of interventions (restrictions in access, logistic, human and financial resources) a phased approach to implementation is proposed. Activities for the first year (phase 1) will be focused on the adaption and standardisation of tools, training and strengthening of structures and mechanisms in preparation for delivery of interventions in Phase 2. In this way, achievements of the first year will build the foundation for subsequent years. In view of the different context and challenges of the three zones, implementation of proposed activities will also be phased by geographical location, depending on access, capacity and resources available.
4.1 Opportunities Restricted access, poor infrastructure and limited means in the face of huge needs means innovative ways of intervening in Somalia are called for. Opportunities arise from existing structures, pilots and programmes which provide entry points for strengthening, scaling up and delivering complementary essential activities. These opportunity areas are summarised below with more detail found in Table 2 of the situational analysis.
• The strength and funding of existing nutrition programmes which provide existing structures through which to deliver essential complementary services (deworming, immunisation, promotion of good hygiene) thereby maximising the potential benefit of nutritional input
• Existing and upcoming interventions and programmes through which quality nutrition activities can be delivered • Accelerated Young Child Survival (AYCS) initiative Child Health Days, GAVI Health System Strengthening (HSS) funded Female Community-based Health Workers & Behaviour Change Communication (BCC) strategy
• Pilot of new interventions with possibilities for scale up – FAO Trials of Improved Practices, Plumpy doz for prevention of moderate malnutrition
• Globally accepted guidelines and proven effective interventions that can be adapted to the Somali context
• WHO community based initiatives (CBI) like Basic Development Needs (BDN) and Healthy City Initiatives – community structures already in place as the basis for community based interventions.
• Mosques and schools provide existing community structures for innovative delivery of population based interventions such as deworming, micronutrient supplementation and nutrition education.
IMPLEMENTATION4
OTP nurse explaining healthy messages to OTP attendants, Baadbuke OTP site Save the Children
14 4.2 PartnershipsImplementation of the strategy will be through partnership-based action, with the national and local authorities (Ministry of Health and other line ministries), with the local community, local NGOs and civil society, with the international community and with the private sector.
a) National and local governmentThroughout the three zones, but more so in Somaliland and Puntland, government structures are in place and evolving. Governments have the responsibility to provide policy direction and leadership, promote inter-ministerial collaboration and advocate with religious and cultural institutions in priority areas. However, capacity is currently inadequate. In response to this, a key output of this strategy is to support the improvement of local capacity and structures within the ministries, in particular technical and financial support for the nutrition sector. Furthermore, this strategy should be included in the respective governments’ plans and priorities for next 3 years.
b) The Community In areas where continuing insecurity and lack of access for international staff persists, implementation through local authorities, local NGOs and community based workers will be key delivery mechanisms. In line with Essential Package of Health Services, UNICEF/WHO’s Accelerated Young Child Survival initiative, the Reproductive Health strategy and GAVI HSS funds, the development of the role of the community health worker is essential for community mobilisation, individual support and promotion of good nutrition, hygiene and health practices.
Furthermore the system of female community-based health workers proposed through GAVI HSS fund will allow expansion of community activities: the promotion of vitamin A for children and post-partum women, prevention and control of diarrhoea, promotion of early initiation and exclusive breastfeeding and appropriate complementary feeding practices for infants and young children, promotion of good nutrition for all the family in particular women, assessment of nutritional status and referral of malnourished children.
Schools, religious and cultural institutions provide important structures within the community through which to deliver population based interventions such as deworming, early identification and referral of acute malnutrition and nutrition education.
c) Local Non Governmental Organisations (NGOs) are very important partners in the delivery of interventions where access to the international community is restricted and government structures are weak. Again, capacity is often a limiting factor and is one of the priority areas to be addressed, in line with national and regional as well as UN national capacity development strategies. The development of regional training and mentoring cells will be an important initiative in improving capacity and the quality of nutrition programmes implemented by these local partners.
d) International community Donors Over recent years, work by FSNAU has achieved a tremendous amount in highlighting the devastating nutrition situation in country and as a consequence, donor funding of emergency programmes has been good. The challenge is to keep nutrition as a priority for donors, UN, NGOs and the ministries and advocate for a longer term strategy in Somalia to address not only the critical acute malnutrition situation but also the underlying causes, if reduced mortality and optimal growth and development are to be addressed.
United Nations (UN) This strategy will build on the already strong collaboration between United Nations (UN) agencies such as UNICEF, FAO/FSNAU, WFP, UNFPA and WHO working to improve maternal and child nutrition and health in Somalia. One key area of collaboration is around strengthening mechanisms to ensure a minimum package of essential services is delivered
15 alongside nutrition programmes in a timely manner.
Under UN humanitarian reform, the cluster approach has been developed to strengthen coordination and give predictability and accountability to the humanitarian response. There are currently nine cluster sectors for Somalia: health, WASH, food aid, agriculture and livelihoods, education, nutrition, protection, logistics and shelter and currently inter cluster working group coordination meetings are held. This strategy places great importance on improving inter cluster and inter working group collaboration for a multi-sector approach to addressing the cross cutting factors that determine nutritional status, growth and development in Somalia.
International Non-Governmental Organizations (NGOs) Although access may be restricted, International NGOs continue to be important partners providing additional technical capacity and skills in nutrition and new innovations in programme delivery.
Academic, Research and Global Advocacy Institutions: A new area to be explored is to access expertise from internationally recognized organizations and improve linkages with local organisations and institutions. Some of these institutions may include: Tufts University, World Alliance for Breastfeeding Action (WABA), International Baby Food Action Network (IBFAN), Micronutrient Initiatives (MI). Links to academic institutions can open up options for the organisation of specific nutrition trainings in the region and distance learning courses.
c) The Private SectorThe private sector in Somalia has an important potential contribution to make towards improving the nutrition situation in country. One of the key areas to engage with the private sector on is the control of the marketing and promotion of breast milk substitutes, possibly looking at supporting the private sector to promote appropriate complementary foods to prevent malnutrition in place of infant formula. Advocacy and sensitisation of the private sector on the International Code on marketing of breast milk substitutes is an important first step towards a longer term consultative process on its adoption. The private sector also has a key role to be explored in the potential for importing fortified foods, in particular cereal flours. In addition, there are opportunities for developing private public partnerships in the social marketing of micronutrient supplements as has been successfully applied to low cost water purification tablets and long lasting insecticide treated bed nets in Somaliland.
4.3 Zonal differencesThe overall goal and outcomes are the same for Somaliland, Puntland and South Central Somalia but the situational analysis provides evidence of the need for a different approach to implementation in the different zones. Coverage of services for the management of acute malnutrition has improved considerably in the last few years. Maintaining these achievements and striving for improved quality of services is particularly important in South Central Somalia where rates of acute malnutrition were found to be the highest of all zones in the recent Post deyr 09/10 seasonal assessment (median GAM 19%, median SAM 4.4%) and 81% of acutely malnourished live. Yet here is where structure and systems through which to implement are more limited and humanitarian space to intervene is most restricted. To overcome these challenges, there is a need to concentrate on implementing through local NGOs and community-based initiatives as government structures emerge and evolve. Until the situation becomes more secure, programmes must be managed by remote control and innovative mechanisms for delivery of interventions developed. Many of the important public health initiatives proposed in the action plan may need to be started on a smaller local basis, to be scaled up as the political and security situation allows.
16 In Somaliland and to a lesser extent Puntland, more or less stable government institutions have been formed providing greater opportunities for partnerships. However as yet, capacity, coordination and policy or regulatory framework is limited. The relative peace and stability allows greater access for intervention, monitoring and supervision. In the north, support needs to focus on the increasing numbers of IDPs who, despite some improvement in acute malnutrition rates between Post Gu 09 and Post Deyr 09/10 seasonal assessments (median GAM down from 20% to 16.7%, median SAM down from 4.8% to 4.2%) remain one of the most nutritionally vulnerable group of all livelihoods, with the highest median stunting rate of 25%.
4.4 Operational researchAlthough extensive information is gathered through FSNAU, FEWSNET, WFP food security and vulnerability assessments, gaps remain in knowledge of many areas including:• local availability of nutrient dense foods, of food habits, taboos and other factors that influence
consumption of nutrient dense foods, •enabling factors and barriers to optimal breast feeding, young child and maternal feeding practices, •economic and cultural dynamics of breast milk substitutes, •opportunities for engagement with private sector in areas of breast milk substitutes and food
fortification, • innovative population based delivery mechanisms for micronutrient supplementation, deworming,
nutrition education and behaviour change communication.
In each of these areas, operational research has been identified as a key activity by which to inform and guide appropriate intervention and links with achieving output 2.2.
4.5 Technical supportThere will be a need to commission consultants with particular expertise in certain areas including economics, food fortification, infant and young child feeding, to provide clearer understanding of current situation, identify potential for future interventions and formulate action plans.
4.6 Behaviour Change CommunicationMany of the output results require attitude and behaviour change on an individual and community basis (early initiation of and exclusive breastfeeding for 6 months, optimal complementary feeding practices, food safety, increased dietary diversity, hygiene practices, demand for micronutrient supplementation and reduction of practices inhibiting micronutrient absorption, appropriate health and nutrition seeking behaviours). There is often overlap with priorities of other sectors eg promotion of food safety goes hand in hand with good hygiene practices. In response, a comprehensive and integrated behaviour change communication strategy approach is needed with the development of key simple messages and the identification of delivery channels that are appropriate and effective in the Somali context. Messages should be communicated through more than one channel for maximum effect: on an individual basis through interpersonal counselling by community health workers and breast feeding counsellors, and mobilising communities through mosques, schools and local institutions and mass media campaigns.
Breastfeeding Counselling, IDPs, Hargeisa, UNICEF Somalia, Iman Morooka
MONITORING5This strategy covers a 3 year period. The overall goal is to contribute to improved survival and development of Somali people through enhanced nutritional status. Trends in under-five and infant mortality rates and nutritional status indicators will be monitored through MICS and FSNAU nutrition surveillance data. However, because three years is too short a period in which to see significant changes these will not be used as the main indicators of the extent to which objectives have been achieved.
The results matrix gives details of the output and outcome (impact) and activity (process) indicators and their source of verification against which effectiveness of the strategy will be measured. The main sources of verification include: FSNAU surveillance data which provides valuable, quality information on a range of indicators; MICS, which was last conducted in 2006 although there were technical issues with the quality of nutrition data in particular, and is planned for 2011 and repeated after 3 years; implementing partner reports and the Health Information System, which has been of low quality and irregular but for which there are ongoing efforts to improve quality through simplification of reporting forms, training, analysis and regular feedback. FSNAU KAPS 2007 and the National Micronutrient and Anthropometric Nutrition Survey 2009 have provided valuable baseline information on a number of key indicators. To facilitate the coordination and monitoring activities of the strategy implementation, responsibility of specific agencies for each activity will be defined.
The strategy will be reviewed and updated on a regular basis not least because the security and access situations can change substantially in Somalia thereby affecting feasibility of implementation. The inter-agency review process of progress on implementation will be led by the Ministries of Health in collaboration with technical support of the Health Sector Committee and undertaken with the involvement of all stakeholders. Line ministries will have a key input into the review process, while the agency focus will depend on the specific activities under review. The annual review will be timed to occur prior to the CAP so findings can inform and identity funding priorities for CAP. Reports on progress will be disseminated to donors, national and implementation partners on an annual basis. A full review of progress made in the implementation of the strategy will be undertaken after the first year (phase 1) and again after the subsequent two years.
ANNEXES
ANNEX 1
18
19 P
roje
ct
de
sc
rip
tio
n
Ind
ica
tors
S
ou
rce
of
ve
rifi
ca
tio
n
As
su
mp
tio
ns
Go
al:
To
co
ntr
ibu
te t
o im
pro
ve
d s
urv
iva
l a
nd
de
ve
lop
me
nt
of
So
ma
li p
eo
ple
th
rou
gh
en
ha
nce
d n
utr
itio
na
l sta
tus
Ou
tco
me
1:
Imp
rove
d a
cce
ss t
o a
nd
utilis
atio
n o
f q
ua
lity s
erv
ice
s
for
the
ma
na
ge
me
nt
of
ma
lnu
tritio
n in
wo
me
n a
nd
ch
ildre
n
1a
75
% a
cu
tely
ma
lno
uri
sh
ed
ch
ildre
n
an
d p
reg
na
nt
an
d la
cta
tin
g w
om
en
ha
ve
acce
ss t
o a
nd
utilis
e q
ua
lity s
erv
ice
s f
or
ma
na
ge
me
nt
of
acu
te m
aln
utr
itio
n
1b
Nu
mb
er
of
he
alth
fa
cili
tie
s p
rovid
ing
se
rvic
es f
or
the
tre
atm
en
t o
f m
icro
nu
trie
nt
de
ficie
ncie
s w
ith
sta
nd
ard
ise
d p
roto
co
ls,
tra
ine
d s
taff
, a
de
qu
ate
an
d t
ime
ly
su
pp
lies
1c 5
0%
id
en
tifie
d h
igh
ris
k p
op
ula
tio
ns
ha
ve
acce
ss t
o a
nd
use
nu
trie
nt
de
nse
su
pp
lem
en
tary
fo
od
to
pre
ve
nt
un
de
rnu
tritio
n
Nu
tritio
n p
rog
ram
me
pe
rfo
rma
nce
in
dic
ato
rs
da
tab
ase
FS
NA
U s
urv
eill
an
ce
da
ta
Co
ve
rag
e s
urv
eys
(lim
ite
d)
HM
IS,
Mo
H r
eco
rds,
facili
ty b
ase
d s
urv
ey
(GA
VI
HS
S)
Acce
ss t
o f
un
ctio
nin
g h
ea
lth
se
rvic
es
Acce
ss t
o f
oo
d s
ecu
rity
Acce
ss t
o h
ea
lth
y
en
vir
on
me
nt
Au
tho
ritie
s,
line
min
istr
ies,
arm
ed
gro
up
s a
re s
up
po
rtiv
e
an
d p
rovid
e n
ece
ssa
ry
co
nd
itio
ns f
or
imp
lem
en
tatio
n
Ou
tpu
ts:
1.1
Q
ua
lity s
erv
ice
s f
or
the
ma
na
ge
me
nt
of
acu
te
ma
lnu
tritio
n a
re e
nh
an
ce
d a
nd
exp
an
de
d
1.2
Q
ua
lity s
erv
ice
s f
or
the
tre
atm
en
t o
f
mic
ron
utr
ien
t d
eficie
ncie
s a
re e
nh
an
ce
d a
nd
exp
an
de
d
1.1
a
70
% o
f ta
rge
ts s
et
for
en
ha
nce
me
nt
& e
xp
an
sio
n o
f o
pe
ratio
na
l S
Cs,
OT
Ps &
SF
Ps b
ase
d o
n b
i a
nn
ua
l
situ
atio
na
l a
na
lysis
, a
re m
et
1.1
b
70
% o
f p
art
ne
rs o
pe
ratin
g w
ith
pe
rfo
rma
nce
in
dic
ato
rs t
ha
t m
ee
t
SP
HE
RE
sta
nd
ard
s
1.2
N
um
be
r o
f h
ea
lth
fa
cili
tie
s
pro
vid
ing
se
rvic
es f
or
the
tre
atm
en
t
of
mic
ron
utr
ien
t d
eficie
ncie
s w
ith
Imp
lem
en
tin
g a
ge
ncie
s’
rep
ort
s
Imp
lem
en
tin
g a
ge
ncie
s’
rep
ort
s
UN
ICE
F d
ata
ba
se
HM
IS,
Mo
H r
eco
rds
Fa
cili
ty b
ase
d s
urv
ey
(GA
VI
HS
S 4
0 M
CH
Pip
elin
e f
un
de
d &
imp
lem
en
ted
Se
cu
rity
allo
ws a
cce
ss f
or
imp
lem
en
tin
g a
ge
ncie
s t
o
op
era
te
Se
cu
rity
allo
ws a
cce
ss f
or
be
ne
ficia
rie
s
Be
ne
ficia
rie
s w
illin
g a
nd
ab
le
to s
ee
k c
are
Fu
nctio
nin
g h
ea
lth
fa
cili
tie
s
LOGICAL FRAMEWORKANNEX 1
1.3
F
oo
d b
ase
d in
terv
en
tio
ns f
or
the
pre
ve
ntio
n o
f
un
de
rnu
tritio
n in
id
en
tifie
d h
igh
ris
k p
op
ula
tio
ns
are
en
ha
nce
d a
nd
exp
an
de
d,
thro
ug
h t
he
he
alth
se
rvic
es a
nd
co
mm
un
ity-b
ase
d
str
uctu
res
1.4
U
tilis
atio
n o
f a
va
ilab
le s
erv
ice
s f
or
the
pre
ve
ntio
n a
nd
tre
atm
en
t o
f a
cu
te a
nd
ch
ron
ic
ma
lnu
tritio
n is in
cre
ase
d
sta
nd
ard
ise
d p
roto
co
ls,
tra
ine
d
sta
ff,
ad
eq
ua
te a
nd
tim
ely
su
pp
lies
in r
ela
tio
n t
o n
ee
d
1.3
5
0%
re
gis
tere
d/e
ligib
le c
hild
ren
in
se
lecte
d in
terv
en
tio
n a
rea
s r
ece
ive
nu
trie
nt
de
nse
su
pp
lem
en
tary
fo
od
1.4
%
re
gis
tere
d/e
ligib
le c
hild
ren
usin
g
ava
ilab
le s
erv
ice
s in
cre
ase
s b
y x
%
ce
ntr
es +
80
He
alth
po
sts
)
He
alth
ca
re p
rovid
ers
tra
inin
g d
ata
ba
se
1
Imp
lem
en
tin
g a
ge
ncie
s
pro
gra
mm
e r
ep
ort
s
Imp
lem
en
tin
g a
ge
ncie
s’
rep
ort
s
Se
cu
rity
situ
atio
n a
llow
s
acce
ss f
or
imp
lem
en
tin
g
ag
en
cie
s a
nd
be
ne
ficia
rie
s
Se
cu
rity
situ
atio
n a
llow
s
acce
ss f
or
imp
lem
en
tin
g
ag
en
cie
s a
nd
re
cip
ien
ts
Activitie
s:
1.1
.1
Ba
se
d o
n b
i a
nn
ua
l re
vie
w o
f n
utr
itio
n s
itu
atio
n,
asse
ss n
ee
ds,
se
t ta
rge
ts a
nd
esta
blis
h n
ew
se
rvic
es f
or
en
ha
nce
me
nt
& e
xp
an
sio
n o
f
op
era
tio
na
l S
Cs,
OT
Ps &
SF
Ps
1.1
.2
Pro
vid
e s
up
plie
s a
nd
te
ch
nic
al su
pp
ort
on
a
tim
ely
ba
sis
1.1
.3
De
ve
lop
an
d im
ple
me
nt
MA
M g
uid
elin
es
sp
ecific
to
So
ma
li co
nte
xt,
in
clu
din
g s
pe
cia
l
att
en
tio
n t
o n
om
ad
ic c
om
mu
nitie
s
1.1
.4
Co
nd
uct
co
mm
un
ity m
ob
ilisa
tio
n w
ith
de
dic
ate
d s
taff
an
d r
eso
urc
es t
o in
cre
ase
co
ve
rag
e &
ea
rly d
iag
no
sis
1.1
.5
Sta
nd
ard
nu
tritio
n p
rog
ram
me
pe
rfo
rma
nce
ind
ica
tors
are
re
po
rte
d m
on
thly
1.1
.1
i) N
ee
ds a
sse
sse
d a
nd
ta
rge
ts s
et
eve
ry s
ix m
on
ths,
ii) N
ew
se
rvic
es
are
in
pla
ce
an
d o
pe
ratio
na
l
1.1
.2
nu
mb
er
of
da
ys s
tock o
uts
1.1
.2b
S
PH
ER
E s
tan
da
rds f
or
pro
gra
mm
e q
ua
lity a
re m
et
by
70
% p
art
ne
rs
1.1
.3
gu
ide
line
s a
re d
eve
lop
ed
an
d
active
ly a
do
pte
d b
y 8
0%
of
pa
rtn
ers
1.1
.4
a)
nu
mb
er
of
co
mm
un
ity
mo
bili
sa
tio
n c
am
pa
ign
s
co
nd
ucte
d b
) p
rop
ort
ion
of
co
mp
lica
ted
to
un
co
mp
lica
ted
SA
M c
ase
s2
1.1
.5
80
% im
ple
me
ntin
g a
ge
ncie
s
rep
ort
ing
mo
nth
ly
Me
etin
g r
ep
ort
s o
f re
vie
w
an
d t
arg
ets
se
t
Imp
lem
en
tin
g a
ge
ncie
s
rep
ort
s
HM
IS,
UN
ICE
F &
WF
P
su
pp
ly d
ata
UN
ICE
F d
ata
ba
se
Pu
blis
he
d g
uid
elin
es,
imp
lem
en
tin
g p
art
ne
rs
rep
ort
s
Imp
lem
en
tin
g p
art
ne
rs
rep
ort
s
UN
ICE
F d
ata
ba
se
Se
cu
rity
situ
atio
n a
llow
s
acce
ss f
or
su
rve
illa
nce
,
imp
lem
en
tatio
n a
nd
utilis
atio
n o
f se
rvic
es
Ad
eq
ua
te h
um
an
, fin
an
cia
l
an
d m
ate
ria
l re
so
urc
es
ava
ilab
le
Eff
icie
nt
log
istics s
yste
m f
or
tim
ely
de
live
ry o
f a
de
qu
ate
su
pp
lies
Ne
w g
uid
elin
es a
cce
pte
d a
nd
ad
op
ted
by p
art
ne
rs
Ta
rge
t p
op
ula
tio
n o
pe
n t
o
me
ssa
ge
s
Re
po
rts a
re r
elia
ble
20
1.1
.6
Ad
vo
ca
te t
o e
nsu
re d
elive
ry o
f b
asic
esse
ntia
l
he
alth
se
rvic
es (
imm
un
isa
tio
n,
de
-wo
rmin
g e
tc)
thro
ug
h n
utr
itio
n p
rog
ram
me
s
1.2
.1
Re
vie
w m
icro
nu
trie
nt
su
rve
y r
esu
lts a
nd
HM
IS
da
ta w
he
re a
va
ila
ble
an
d s
et
targ
ets
fo
r
en
ha
nce
me
nt
of
MN
D t
rea
tme
nt
se
rvic
es
1.2
.2
De
ve
lop
& im
ple
me
nt
sim
ple
So
ma
li s
pe
cific
sta
nd
ard
ise
d p
roto
co
ls f
or
the
tre
atm
en
t o
f
mic
ron
utr
ien
t d
eficie
ncie
s,
with
re
gio
na
l ro
ll o
ut
1.2
.3
De
ve
lop
an
d im
ple
me
nt
sim
ple
sta
nd
ard
ise
d
pro
toco
l fo
r th
era
pe
utic z
inc s
up
ple
me
nta
tio
n in
the
ma
na
ge
me
nt
of
dia
rrh
oe
a
1.2
.4
Pro
vid
e a
nd
ma
na
ge
su
pp
lie
s a
nd
pro
vid
e
tech
nic
al su
pp
ort
on
a t
ime
ly b
asis
1.2
.5
Pla
n a
nd
im
ple
me
nt
in-s
erv
ice
tra
inin
g o
f
he
alth
fa
cility s
taff
at
all le
ve
ls o
n d
iag
no
sis
an
d
tre
atm
en
t p
roto
co
ls
1.2
.6
Co
nd
uct
co
mm
un
ity m
ob
ilis
atio
n c
am
pa
ign
s o
n
MN
D
1.3
.1
Asse
ss n
ee
ds a
nd
id
en
tify
vu
lne
rab
le
po
pu
latio
ns t
hro
ug
h b
i a
nn
ua
l re
vie
w o
f q
ua
lity
nu
tritio
n a
nd
fo
od
se
cu
rity
se
aso
na
l
asse
ssm
en
ts
1.3
.2
Ba
se
d o
n a
bo
ve
, e
sta
blish
ne
w n
utr
itio
n
se
rvic
es f
or
pre
ve
ntio
n o
f u
nd
ern
utr
itio
n,
1.1
.6
Ad
vo
ca
cy is c
arr
ied
ou
t
1.2
.1
Su
rve
y r
esu
lts a
nd
HM
IS d
ata
revie
we
d a
nd
ta
rge
ts s
ets
1.2
.2
a)
Sta
nd
ard
ise
d p
roto
co
ls
de
ve
lop
ed
by e
nd
of
ph
ase
1
b)
incre
asin
g t
ren
ds in
x%
he
alth
facilitie
s im
ple
me
ntin
g t
rea
tme
nt
pro
toco
ls a
cro
ss t
he
re
gio
ns
3
1.2
.3
a
) S
tan
da
rdis
ed
pro
toco
ls
de
ve
lop
ed
by e
nd
of
ph
ase
1
b
) 8
0%
ch
ild
ren
att
en
din
g M
CH
exp
eri
en
cin
g d
iarr
ho
ea
wh
o
rece
ive
th
era
pe
utic z
inc
su
pp
lem
en
tatio
n b
y e
nd
ph
ase
2
1.2
.4
Nu
mb
er
of
da
ys o
f sto
ck o
uts
of
mic
ron
utr
ien
t tr
ea
tme
nts
1.2
.5
a)
Nu
mb
er
of
he
alth
fa
cilitie
s w
ith
sta
ff t
rain
ed
an
d a
ctive
in
tre
atm
en
t o
f m
icro
nu
trie
nt
de
ficie
ncie
s
1.2
.6
Nu
mb
er
of
ca
mp
aig
ns c
on
du
cte
d
1.2
.1
Bi a
nn
ua
l re
vie
w c
on
du
cte
d a
nd
targ
et
po
pu
latio
ns id
en
tifie
d
1.2
.2
Fo
od
-ba
se
d in
terv
en
tio
ns t
o
pre
ve
nt
un
de
rnu
tritio
n a
re
Do
cu
me
nta
tio
n
Do
cu
me
nta
tio
n
Do
cu
me
nta
tio
n
HM
IS
Fa
cility s
urv
ey
Do
cu
me
nta
tio
n
HM
IS
HM
IS s
up
ply
da
ta
Ne
w d
ata
ba
se
on
he
alth
pe
rso
nn
el &
tra
inin
g
rece
ive
d
Activity r
ep
ort
s
Re
po
rts o
f re
vie
w a
nd
targ
ets
id
en
tifie
d
Imp
lem
en
tin
g a
ge
ncie
s
rep
ort
s
He
alth
se
cto
r re
ce
ptive
,
ad
eq
ua
te s
up
plie
s a
nd
log
istic s
yste
m a
va
ila
ble
Re
su
lts a
re r
elia
ble
Su
ffic
ien
t su
pp
lie
s a
nd
eff
icie
nt
log
istica
l su
pp
ort
ava
ila
ble
He
alth
fa
cility s
taff
mo
tiva
ted
Co
mm
un
ity r
ece
ptive
Da
ta a
nd
re
vie
w a
re r
elia
ble
Su
pp
lem
en
tary
fo
od
s a
re
acce
pta
ble
to
an
d u
se
d
21
22
(in
clu
din
g lip
id-b
ase
d n
utr
ien
t su
pp
lem
en
ts-
LN
S)
in id
en
tifie
d h
igh
ris
k p
op
ula
tio
ns
1.3
.3
Co
nd
uct
tra
inin
g o
f h
ea
lth
wo
rke
rs a
nd
imp
lem
en
tin
g p
art
ne
rs o
n n
ew
se
rvic
es,
inclu
din
g c
ou
nse
llin
g o
n c
on
tin
ue
d
bre
astf
ee
din
g a
nd
fo
od
hyg
ien
e p
ractice
s
1.3
.4
Pro
vid
e a
nd
ma
na
ge
su
pp
lies a
nd
pro
vid
e
tech
nic
al su
pp
ort
to
im
ple
me
ntin
g p
art
ne
rs o
n
a t
ime
ly b
asis
1.3
.5
Co
nd
uct
co
mm
un
ity s
en
sitis
atio
n t
o m
axim
ise
acce
pta
bili
ty a
nd
ap
pro
pri
ate
use
of
foo
d b
ase
d
inte
rve
ntio
ns
1.3
.6
Asse
ss a
nd
re
vie
w c
on
tin
ua
tio
n o
f fo
od
ba
se
d
inte
rve
ntio
ns,
ba
se
d o
n n
utr
itio
n s
urv
eill
an
ce
da
ta a
nd
bi a
nn
ua
l se
aso
na
l a
sse
ssm
en
ts
1.4
.1
C
on
du
ct
co
mm
un
ity a
wa
ren
ess a
nd
mo
bili
sa
tio
n c
am
pa
ign
s t
o in
cre
ase
aw
are
ne
ss
an
d u
nd
ers
tan
din
g o
f a
va
ilab
le s
erv
ice
s
esta
blis
he
d in
id
en
tifie
d h
igh
ris
k
are
as
1.2
.3
Nu
mb
er
of
he
alth
wo
rke
rs a
nd
imp
lem
en
tin
g s
taff
tra
ine
d
1.2
.4
Nu
mb
er
of
da
ys o
f sto
ck o
uts
1.2
.5
Nu
mb
er
of
co
mm
un
ity
se
nsitis
atio
n c
am
pa
ign
s
co
nd
ucte
d
1.2
.6
Bi a
nn
ua
l re
vie
ws c
on
du
cte
d
1.4
.1
nu
mb
er
of
co
mm
un
ity c
am
pa
ign
s
co
nd
ucte
d
Tra
inin
g r
ep
ort
s,
he
alth
wo
rke
r tr
ain
ing
da
tab
ase
,
pa
rtn
er
rep
ort
s
Su
pp
ly d
ata
Activity r
ep
ort
s
Re
vie
w r
ep
ort
s
Activity r
ep
ort
s
ap
pro
pri
ate
ly b
y t
arg
et
gro
up
s
He
alth
wo
rke
rs a
nd
pro
gra
mm
e s
taff
are
mo
tiva
ted
Su
ffic
ien
t su
pp
lies a
nd
eff
icie
nt
log
istics s
yste
m in
pla
ce
Co
mm
un
ity is r
ece
ptive
Su
rve
illa
nce
da
ta is r
elia
ble
Co
mm
un
ity is r
ece
ptive
23
Ou
tco
me
2
Pro
jec
t d
es
cri
pti
on
Ind
ica
tors
S
ou
rce
of
ve
rifi
ca
tio
n
As
su
mp
tio
ns
Ou
tco
me
2:
Su
sta
ine
d a
va
ila
bility o
f tim
ely
an
d q
ua
lity
nu
tritio
n
info
rma
tio
n a
nd
op
era
tio
na
l re
se
arc
h in
to e
ffe
ctive
resp
on
se
s t
o a
dd
ress t
he
ca
use
s o
f u
nd
ern
utr
itio
n
Nu
mb
er
of
info
rma
tio
n u
se
rs
(go
ve
rnm
en
t, in
stitu
tio
ns,
civ
il s
ocie
ty,
Dia
sp
ora
, IN
GO
s,
UN
ag
en
cie
s,
do
no
rs,
oth
ers
) re
ce
ivin
g n
utr
itio
n in
form
atio
n t
o
incre
ase
by 4
0%
aft
er
3 y
ea
rs
Nu
mb
er
of
info
rma
tio
n u
se
rs b
ase
d in
So
ma
lia
re
ce
ivin
g n
utr
itio
n in
form
atio
n t
o
incre
ase
by 4
0%
aft
er
3 y
ea
rs
Evid
en
ce
of
FS
NA
U a
na
lysis
be
ing
pri
ma
ry in
form
an
t to
hu
ma
nita
ria
n a
pp
ea
l
an
d r
esp
on
se
pro
ce
ss a
nd
evid
en
ce
of
ch
an
ge
s in
th
e r
esp
on
se
an
d
pro
ce
ss(C
AP
/HR
F/C
ER
F)
Evid
en
ce
of
nu
tritio
n a
na
lysis
in
form
ing
the
Re
co
nstr
uctio
n &
De
ve
lop
me
nt
Pla
n
(RD
P),
Un
ite
d N
atio
ns T
ran
sitio
n P
lan
(UN
TP
), A
gri
cu
ltu
re S
ecto
r S
tra
teg
ic
Fra
me
wo
rk (
AS
SF
), a
nd
Co
un
try S
tra
teg
y
Pa
pe
r (C
SP
) a
nd
evid
en
ce
of
ch
an
ge
s in
the
de
sig
n a
nd
mo
nito
rin
g o
f th
ese
initia
tive
s
Evid
en
ce
of
nu
tritio
n a
na
lysis
in
form
ing
the
So
ma
lia
Su
pp
ort
Se
cre
tari
at
(SS
S)
So
ma
lia
nu
tritio
n
info
rma
tio
n a
ge
ncy
we
bsite
hits (
FS
NA
U,
UN
ICE
F,
WH
O,
OC
HA
), m
ailin
g lis
ts,
me
etin
g p
art
icip
atio
n,
nu
tritio
n u
nit o
f M
oH
s
CA
P,
CE
RF
, H
RF
rep
ort
s
RD
P d
ocu
me
nt
Clu
ste
r m
ee
tin
g
Pa
rtn
ers
an
d d
on
ors
rece
ptive
to
nu
tritio
n
info
rma
tio
n
Nu
tritio
n in
form
atio
n is
inte
rpre
ted
ap
pro
pri
ate
ly t
o
info
rm d
ecis
ion
s r
eg
ard
ing
fea
sib
le r
esp
on
se
s
Se
cu
rity
situ
atio
n a
llo
ws
acce
ss t
o r
esp
on
d t
o
nu
tritio
n in
form
atio
n
ava
ila
ble
Au
tho
ritie
s,
lin
e m
inis
trie
s,
arm
ed
gro
up
s a
re
su
pp
ort
ive
an
d p
rovid
e
ne
ce
ssa
ry c
on
ditio
ns t
o
resp
on
d
24 se
cto
r w
ork
ing
gro
up
s a
nd
th
e I
AS
C
Clu
ste
r a
ctio
n p
lan
s a
nd
evid
en
ce
of
de
cis
ion
s in
flu
en
ce
d b
y t
his
an
aly
sis
Nu
tritio
n
an
aly
sis
an
d in
form
atio
n
co
ntr
ibu
tin
g t
o 5
0%
of
the
se
cto
r stu
die
s
an
d s
tra
teg
ic p
lan
nin
g u
nd
ert
ake
n b
y
So
ma
li g
ove
rnm
en
t, d
on
ors
, U
N
ag
en
cie
s,
ING
Os
min
ute
s
Str
ate
gic
pla
nn
ing
rep
ort
s
Ou
tpu
ts:
2.1
Q
ua
lity
nu
tritio
na
l su
rve
illa
nce
, m
on
ito
rin
g a
nd
eva
lua
tio
n is c
on
du
cte
d a
nd
re
vie
we
d o
n a
tim
ely
ba
sis
to
in
form
th
e t
arg
etin
g o
f vu
lne
rab
le
po
pu
latio
ns w
ith
ap
pro
pri
ate
re
sp
on
se
s
2.2
O
pe
ratio
na
l re
se
arc
h t
o id
en
tify
eff
ective
pro
gra
mm
es t
o a
dd
ress t
he
ca
use
s o
f
un
de
rnu
tritio
n is c
on
du
cte
d,
acco
rdin
g t
o a
n a
gre
ed
up
on
se
t o
f p
rio
ritie
s a
nd
pla
n o
f a
ctio
n,
an
d is u
se
d
as e
vid
en
ce
ba
se
fo
r lo
ng
te
rm s
tra
teg
ic p
lan
nin
g
2.1
a 1
00
% s
urv
eys a
re v
alid
ate
d u
sin
g
pla
usib
ility c
he
cks.
2.1
b >
90
% o
f su
rve
ys m
ee
t th
e c
rite
ria
of
qu
ality
fo
r p
ub
lish
ing
re
su
lts
2.1
b R
esu
lts o
f b
ian
nu
al n
utr
itio
n
asse
ssm
en
ts a
re r
ele
ase
d a
nd
re
vie
we
d
in J
an
ua
ry (
po
st
De
yr)
an
d A
ug
ust
(po
st
Gu
) o
f e
ach
ye
ar
2.2
x%
re
se
arc
h p
roje
cts
un
de
rta
ke
n
acco
rdin
g t
o d
efin
ed
pla
n o
f a
ctio
n4
FS
NA
U t
ech
nic
al se
rie
s
rep
ort
s
Do
cu
me
nta
tio
n o
f
FS
NA
U s
ea
so
na
l
asse
ssm
en
t re
lea
se
da
tes
Do
cu
me
nta
tio
n o
f
nu
mb
er
of
rese
arc
h
rep
ort
s p
rod
uce
d
Da
ta c
olle
ctio
n is r
elia
ble
Activitie
s
2.1
.1
Co
nd
uct
reg
ula
r in
ter-
ag
en
cy n
utr
itio
n s
urv
eys
thro
ug
ho
ut
live
lih
oo
d z
on
es a
cco
rdin
g t
o
ag
ree
d u
po
n s
ch
ed
ule
an
d in
ter-
se
cto
ral
info
rma
tio
n r
eq
uir
em
en
ts.
2.1
.1a
>9
0%
pla
nn
ed
nu
tritio
n s
urv
eys
co
nd
ucte
d
2.1
.1b
Pa
rtn
ers
in
vo
lve
d in
10
0%
of
the
su
rve
ys f
or
ow
ne
rsh
ip
2.1
.1c 1
00
% p
re-a
gre
ed
in
ter-
se
cto
ral
FS
NA
U t
ech
nic
al se
rie
s
rep
ort
s,
Bi m
on
thly
Nu
tritio
n U
pd
ate
s
Se
cu
rity
situ
atio
n a
llo
ws
acce
ss
Su
ffic
ien
t fin
an
cia
l, h
um
an
reso
urc
es a
nd
ma
teri
al
25
2.1
.2
An
aly
se
su
rve
y r
esu
lts a
nd
in
terp
ret
in c
on
text
of
oth
er
rele
va
nt
su
rve
illa
nce
da
ta (
MC
H d
ata
,
ava
ilab
ility
of
nu
tritio
n p
rog
ram
me
s,
acce
ss t
o
he
alth
se
rvic
es,
dis
ea
se
ou
tbre
aks,
wa
ter
an
d
sa
nita
tio
n,
foo
d s
ecu
rity
in
form
atio
n)
2.1
.3
Un
de
rta
ke
bia
nn
ua
l m
ap
pin
g o
f n
utr
itio
n
situ
atio
n b
y liv
elih
oo
d z
on
e,
acco
rdin
g t
o I
PC
cla
ssific
atio
n
2.1
.4
Pro
du
ce
re
gu
lar
nu
tritio
n u
pd
ate
s a
nd
re
po
rts
inclu
din
g:
Qu
art
erl
y F
oo
d s
ecu
rity
an
d n
utr
itio
n
bri
ef,
Bia
nn
ua
l F
oo
d S
ecu
rity
an
d N
utr
itio
n
bri
ef,
bi a
nn
ua
l te
ch
nic
al se
rie
s r
ep
ort
s.
2.2
.1
Pri
ori
ty a
rea
s f
or
op
era
tio
na
l re
se
arc
h in
to
un
de
rlyin
g c
au
se
s o
f u
nd
ern
utr
itio
n id
en
tifie
d
an
d p
lan
of
actio
n d
evis
ed
to
in
clu
de
activitie
s
3.1
.1,
3.2
.1,
3.3
.1,
3.4
.1,
3.5
.3,
4.2
.6,
4.2
.8
2.2
.2
Co
nd
uct
op
era
tio
na
l re
se
arc
h a
cco
rdin
g t
o p
lan
of
actio
n
2.2
.3
Pro
du
ce
re
se
arc
h r
ep
ort
s,
dis
se
min
ate
an
d u
se
fin
din
gs t
o in
form
ap
pro
pri
ate
nu
tritio
n
resp
on
se
s
info
rma
tio
n r
eq
uir
em
en
ts (
WA
SH
,
He
alth
, M
ala
ria
, F
oo
d S
ecu
rity
)
ad
dre
sse
d
2.1
.2 1
00
% p
ub
lish
ed
su
rve
y r
ep
ort
s
inclu
de
co
nte
xtu
al a
na
lysis
2.1
.3 M
ap
s p
rod
uce
d o
n a
bia
nn
ua
l b
asis
2.1
.4 N
utr
itio
n r
ep
ort
s p
rod
uce
d a
cco
rdin
g
to d
efin
ed
sch
ed
ule
2.2
.1 L
ist
of
pri
ori
tie
s a
rea
s a
nd
pla
n o
f
actio
n id
en
tifie
d
2.2
.2 R
ese
arc
h is c
on
du
cte
d
2.2
.3 R
ese
arc
h r
ep
ort
s p
ub
lish
ed
an
d
dis
se
min
ate
d
Ma
ps p
rod
uce
d
Re
po
rts p
rod
uce
d
Pu
blis
he
d r
ep
ort
s
reso
urc
es a
va
ilab
le
Imp
lem
en
tin
g p
art
ne
rs,
au
tho
ritie
s,
line
min
istr
ies,
arm
ed
gro
up
s a
re
su
pp
ort
ive
an
d p
rovid
e
ne
ce
ssa
ry c
on
ditio
ns t
o
co
nd
uct
su
rve
ys &
re
se
arc
h
26 O
utc
om
e 3
Pro
jec
t d
es
cri
pti
on
Ind
ica
tors
S
ou
rce
of
ve
rifi
ca
tio
n
As
su
mp
tio
ns
Ou
tco
me
3:
Incre
ase
d a
pp
rop
ria
te k
no
wle
dg
e,
att
itu
de
s a
nd
pra
ctice
s r
eg
ard
ing
in
fan
t, y
ou
ng
ch
ild
an
d m
ate
rna
l
nu
tritio
n
50
% in
cre
ase
in
ap
pro
pri
ate
kn
ow
led
ge
,
att
itu
de
s a
nd
pra
ctice
s r
eg
ard
ing
in
fan
t,
yo
un
g c
hild
an
d m
ate
rna
l n
utr
itio
n
KA
P s
tud
y
MIC
S
Acce
ss t
o f
un
ctio
nin
g h
ea
lth
se
rvic
es
Acce
ss t
o f
oo
d s
ecu
rity
Acce
ss t
o h
ea
lth
y
en
vir
on
me
nt
Ou
tpu
ts:
3.1
Im
pro
ve
d r
ate
s o
f e
arl
y in
itia
tio
n a
nd
exclu
siv
e
bre
astf
ee
din
g p
ractice
s
3.2
Im
pro
ve
d r
ate
s o
f o
ptim
al co
mp
lem
en
tary
fe
ed
ing
pra
ctice
s
3.3
Lo
ca
l a
va
ila
bility a
nd
co
nsu
mp
tio
n p
att
ern
s o
f
nu
trie
nt
de
nse
fo
od
s a
re b
ett
er
un
de
rsto
od
an
d
kn
ow
led
ge
-ba
se
is u
se
d t
o p
rom
ote
in
cre
ase
d
inta
ke
of
en
erg
y,
pro
tein
an
d m
icro
nu
trie
nt-
rich
foo
ds
3.4
Co
mm
on
p
ractice
s
tha
t in
hib
it
mic
ron
utr
ien
t
ab
so
rptio
n a
re b
ett
er
un
de
rsto
od
an
d a
dd
resse
d
3.5
Im
pro
ve
d a
cce
ss t
o n
utr
itio
n c
ou
nse
llin
g f
or
pre
gn
an
t a
nd
la
cta
tin
g w
om
en
th
rou
gh
he
alth
se
rvic
es a
nd
co
mm
un
ity b
ase
d s
tru
ctu
res
3.1
R
ate
s o
f e
arl
y in
itia
tio
n a
nd
exclu
siv
e b
rea
stf
ee
din
g d
ou
ble
fro
m
ba
se
lin
e (
5%
)5
3.2
R
ate
s o
f o
ptim
al co
mp
lem
en
tary
fee
din
g p
ractice
s –
ag
e a
t
intr
od
uctio
n,
die
tary
div
ers
ity,
me
al
fre
qu
en
cy –
do
ub
le f
rom
ba
se
lin
e
(11
%)6
3.3
a
) L
oca
l a
va
ila
bility a
nd
co
nsu
mp
tio
n
pa
tte
rns o
f n
utr
ien
t d
en
se
fo
od
s a
re
ide
ntifie
d,
do
cu
me
nte
d a
nd
use
d in
BC
C
3.4
R
ed
uctio
n in
co
mm
on
pra
ctice
s t
ha
t
inh
ibit m
icro
nu
trie
nt
ab
so
rptio
n
(ba
se
lin
e f
req
ue
nt
tea
co
nsu
mp
tio
n
72
%)7
3.5
a
80
% p
reg
na
nt
an
d la
cta
tin
g w
om
en
att
en
din
g M
CH
se
rvic
es a
cce
ss
nu
tritio
n c
ou
nse
llin
g
MIC
S,
Mic
ron
utr
ien
t
su
rve
y
MIC
S,
FS
NA
U
ho
use
ho
ld n
utr
itio
n
asse
ssm
en
t d
ata
,
CS
I –
co
pin
g s
tra
teg
ies
ind
ex
Re
po
rt
HM
IS
Se
cu
rity
situ
atio
n a
llo
ws
acce
ss f
or
imp
lem
en
tatio
n
an
d u
tilisa
tio
n o
f se
rvic
es
27
3.5
b N
um
be
r o
f p
reg
na
nt
an
d la
cta
tin
g
wo
me
n r
ece
ivin
g n
utr
itio
n
co
un
se
llin
g t
hro
ug
h c
om
mu
nity
ba
se
d d
elive
ry m
ech
an
ism
Activity r
ep
ort
s
Ta
rge
t g
rou
ps c
om
ply
with
ad
vic
e
Activitie
s:
3.1
.1
Co
nd
uct
form
ative
re
se
arc
h t
o u
nd
ers
tan
d
cu
rre
nt
pra
ctice
s &
asse
ss b
arr
iers
an
d
op
po
rtu
nitie
s t
o o
ptim
al b
rea
st
fee
din
g
pra
ctice
s
3.1
.2
De
ve
lop
an
d im
ple
me
nt
an
IY
CF
tra
inin
g p
lan
an
d c
urr
icu
la f
or
co
mm
un
ity b
ase
d
bre
astf
ee
din
g c
ou
nse
llo
rs (
BF
C)
an
d M
CH
sta
ff,
inclu
din
g t
rain
ing
of
ma
ste
r tr
ain
ers
3.1
.3
Pro
vid
e in
div
idu
al co
un
se
llin
g a
nd
su
pp
ort
fo
r
exclu
siv
e b
rea
st
fee
din
g t
hro
ug
h a
ne
two
rk o
f
tra
ine
d c
om
mu
nity b
ase
d B
FC
& M
CH
sta
ff
3.1
.4
Re
vie
w a
nd
ad
ap
t IA
SC
/ E
NN
/IF
E ‘In
teg
ratio
n
of
IYC
F s
up
po
rt in
to C
MA
M’ m
ate
ria
ls t
o t
he
So
ma
li c
on
text
3.1
.5
Pilo
t In
teg
ratio
n o
f IY
CF
su
pp
ort
in
to C
MA
M
ap
pro
ach
in
sp
ecifie
d O
TP
s
3.1
.6
De
ve
lop
an
d d
isse
min
ate
ke
y m
essa
ge
s &
ma
teri
als
fo
r m
ob
ilis
ing
co
mm
un
ity s
up
po
rt f
or
op
tim
al b
rea
stf
ee
din
g t
hro
ug
h a
pp
rop
ria
te
de
live
ry s
tra
teg
ies,
inclu
din
g g
ran
dm
oth
ers
,
relig
iou
s/c
om
mu
nity g
rou
ps a
nd
le
ad
ers
an
d
ma
ss m
ed
ia c
ha
nn
els
3.1
.7
Co
nd
uct
ma
rke
t ch
ain
an
aly
sis
of
bre
ast
milk
su
bstitu
tes
3.1
.8
En
ga
ge
with
pri
va
te s
ecto
r a
nd
de
ve
lop
&
imp
lem
en
t a
n a
dvo
ca
cy s
tra
teg
y f
or
3.1
.1 B
arr
iers
& o
pp
ort
un
itie
s id
en
tifie
d
3.1
.2a
ma
ste
r tr
ain
ers
are
tra
ine
d
3.1
.2b
cu
rric
ulu
m is d
eve
lop
ed
3.1
.2c t
rain
ing
pla
n is im
ple
me
nte
d
3.1
.3a
nu
mb
er
of
BF
C t
rain
ed
an
d a
ctive
3.1
.3b
nu
mb
er
MC
H c
en
tre
s p
rovid
ing
bre
astf
ee
din
g c
ou
nse
llin
g
3.1
.4 M
ate
ria
ls a
da
pte
d b
y e
nd
of
ph
ase
1
3.1
.5 P
ilo
ts c
on
du
cte
d in
sp
ecifie
d O
TP
s
3.1
.6a
IE
C m
ate
ria
ls d
eve
lop
ed
3.1
.6b
Me
ssa
ge
s d
isse
min
ate
d t
hro
ug
h
ide
ntifie
d d
elive
ry s
tra
teg
ies
3.1
.7 R
ep
ort
is c
om
ple
ted
an
d
dis
se
min
ate
d
3.1
.8 A
dvo
ca
cy s
tra
teg
y is d
eve
lop
ed
Re
se
arc
h r
ep
ort
Activity r
ep
ort
s
Cu
rric
ulu
m d
ocu
me
nt
pu
blish
ed
Re
po
rts
Fa
cility s
urv
ey (
GA
VI
HS
S)
Do
cu
me
nta
tio
n
Imp
lem
en
tin
g p
art
ne
r
rep
ort
s
Pu
blish
ed
ma
teri
als
Do
cu
me
nta
tio
n
Pu
blish
ed
re
po
rt
Pu
blish
ed
str
ate
gy
Fin
din
gs a
re r
elia
ble
Co
un
se
llo
rs a
re m
otiva
ted
to p
rovid
e s
up
po
rt
He
alth
fa
cility s
taff
are
mo
tiva
ted
to
pro
vid
e
co
un
se
llin
g
Re
so
urc
es a
va
ila
ble
Se
cu
rity
situ
atio
n a
llo
ws
Co
mm
un
ity g
rou
ps e
tc
willin
g t
o e
ng
ag
e
Ta
rge
t a
ud
ien
ce
re
ce
ptive
to n
ew
me
ssa
ge
s e
ve
n if
co
ntr
ary
to
tra
ditio
na
l b
elie
fs
Pri
va
te s
ecto
r w
illin
g t
o
en
ga
ge
, re
ce
ptive
to
28
tra
de
rs/im
po
rte
rs o
f b
rea
st
milk s
ub
stitu
tes
3.1
.9
Co
nd
uct
se
nsitis
atio
n o
n t
he
pri
ncip
les a
nd
aim
s o
f In
tern
atio
na
l co
de
of
Ma
rke
tin
g o
f
Bre
ast
milk S
ub
stitu
tes w
ith
vie
w t
o a
ll p
art
ies
ad
op
tin
g a
nd
sig
nin
g
3.1
.10
D
eve
lop
a r
oa
d m
ap
fo
r th
e d
raft
ing
an
d
imp
lem
en
tatio
n o
f a
lo
ca
l C
od
e o
f M
ark
etin
g o
f
Bre
ast
milk s
ub
stitu
tes
3.2
.1
Co
nd
uct
form
ative
re
se
arc
h t
o a
sse
ss e
na
blin
g
facto
rs a
nd
b
arr
iers
to
o
ptim
al
co
mp
lem
en
tary
fee
din
g p
ractice
s
3.2
.2
De
ve
lop
an
d im
ple
me
nt
a t
rain
ing
pla
n a
nd
cu
rric
ula
fo
r co
mm
un
ity b
ase
d w
ork
ers
an
d
he
alth
fa
cility s
taff
(in
teg
rate
in
to e
xis
tin
g
cu
rric
ula
fo
r C
HW
& M
CH
& T
BA
)
3.2
.3
De
ve
lop
ke
y r
eg
ion
-sp
ecific
me
ssa
ge
s a
nd
recip
es f
or
op
tim
al co
mp
lem
en
tary
fe
ed
ing
pra
ctice
s a
nd
in
teg
rate
with
sim
ple
me
ssa
ge
s
on
fo
od
sa
fety
an
d g
oo
d h
yg
ien
e p
ractice
s
3.2
.4
Dis
se
min
ate
me
ssa
ge
s t
hro
ug
h e
ffe
ctive
de
live
ry m
ech
an
ism
s in
clu
din
g in
div
idu
al
co
un
se
llin
g,
sch
oo
ls,
relig
iou
s/c
om
mu
nity
gro
up
s &
le
ad
ers
an
d m
ass m
ed
ia c
ha
nn
els
3.3
.1
Co
nd
uct
form
ative
re
se
arc
h o
n i
de
ntifica
tio
n o
f
loca
lly
ava
ila
ble
n
utr
ien
t d
en
se
fo
od
s
an
d
ha
bits,
tab
oo
s,
pra
ctice
s
tha
t in
flu
en
ce
th
eir
co
nsu
mp
tio
n
3.3
.2
Ba
se
d o
n a
bo
ve
, d
eve
lop
ke
y m
essa
ge
s a
nd
recip
es t
o p
rom
ote
co
nsu
mp
tio
n o
f a
pp
rop
ria
te
3.1
.9 S
en
sitis
atio
n is c
on
du
cte
d
3.1
.10
Ro
ad
ma
p is d
eve
lop
ed
3.2
.1 E
na
blin
g f
acto
rs a
nd
ba
rrie
rs a
re
ide
ntifie
d
3.2
.2a
Cu
rric
ula
& t
rain
ing
pla
n is
de
ve
lop
ed
3.2
.2b
Nu
mb
er
of
he
alth
wo
rke
rs t
rain
ed
in o
ptim
al co
mp
lem
en
tary
fe
ed
ing
pra
ctice
s
3.2
.3
Me
ssa
ge
s a
nd
re
cip
es a
re
de
ve
lop
ed
3.2
.4 B
CC
im
ple
me
nte
d
3.3
.1 R
ese
arc
h c
on
du
cte
d &
fin
din
gs
dis
se
min
ate
d
3.3
.2 K
ey m
essa
ge
s d
eve
lop
ed
&
dis
se
min
ate
d
Imp
lem
en
tin
g p
art
ne
r
rep
ort
s
Pu
blish
ed
ro
ad
ma
p
Re
se
arc
h r
ep
ort
Re
po
rts
Da
tab
ase
on
tra
ine
d
he
alth
wo
rke
rs
Re
po
rts
Activity r
ep
ort
s
Re
se
arc
h r
ep
ort
Activity r
ep
ort
s
ad
vo
ca
cy
Fin
din
gs a
re r
elia
ble
He
alth
sta
ff a
re m
otiva
ted
to
pro
vid
e c
ou
nse
llin
g
Ta
rge
t a
ud
ien
ce
re
ce
ptive
to n
ew
me
ssa
ge
s e
ve
n if
co
ntr
ary
to
tra
ditio
na
l b
elie
fs
Institu
tio
ns in
th
e
me
ch
an
ism
are
willin
g t
o
acce
pt
ne
w in
no
va
tio
n
Co
mm
un
ity w
illin
g t
o s
ha
re
kn
ow
led
ge
an
d in
form
atio
n
Ta
rge
t a
ud
ien
ce
re
ce
ptive
to n
ew
me
ssa
ge
s e
ve
n if
29 n
utr
ien
t d
en
se
fo
od
s,
inclu
din
g
se
afo
od
a
nd
off
al,
an
d
dis
se
min
ate
to
g
en
era
l p
op
ula
tio
n
thro
ug
h a
pp
rop
ria
te c
om
mu
nity b
ase
d d
elive
ry
ch
an
ne
ls
3.3
.3
Lin
k
with
a
gri
cu
ltu
re/liv
elih
oo
ds
se
cto
r to
pro
mo
te
pro
du
ctio
n
&
utilisa
tio
n
of
loca
lly
ava
ila
ble
nu
trie
nt
de
nse
fo
od
s
3.3
.4
Lin
k
with
a
gri
cu
ltu
re/liv
elih
oo
ds
se
cto
r to
incre
ase
un
de
rsta
nd
ing
an
d u
se
of
ap
pro
pri
ate
foo
d p
rese
rva
tio
n t
ech
niq
ue
s e
sp
ecia
lly o
f m
ilk
an
d m
ilk p
rod
ucts
3.4
.1
Co
nd
uct
form
ative
re
se
arc
h t
o id
en
tify
co
mm
on
pra
ctice
s t
ha
t ca
use
sig
nific
an
t in
hib
itio
n o
f
mic
ron
utr
ien
t a
bso
rptio
n f
rom
die
t
3.4
.2
De
ve
lop
ke
y m
essa
ge
s a
ime
d a
t re
du
cin
g
the
se
pra
ctice
s a
nd
dis
se
min
ate
to
ge
ne
ral
po
pu
latio
n t
hro
ug
h a
pp
rop
ria
te c
om
mu
nity
ba
se
d d
elive
ry c
ha
nn
els
3.5
.1
D
eve
lop
an
d im
ple
me
nt
tra
inin
g p
lan
an
d
cu
rric
ula
on
nu
tritio
n c
ou
nse
llin
g s
kills
fo
r
pre
gn
an
t a
nd
la
cta
tin
g w
om
en
fo
r C
HW
& M
CH
sta
ff
3.5
.2
M
CH
sta
ff p
rovid
e a
pp
rop
ria
te n
utr
itio
n
co
un
se
llin
g (
inclu
din
g lo
ca
l fo
od
de
mo
nstr
atio
ns)
at
an
ten
ata
l a
nd
po
st
na
tal
vis
its
3.5
.3
Co
nd
uct
tria
ls t
o id
en
tify
in
no
va
tive
po
pu
latio
n
ba
se
d d
elive
ry m
ech
an
ism
fo
r n
utr
itio
n
co
un
se
llin
g f
or
pre
gn
an
t a
nd
la
cta
tin
g w
om
en
3.5
.4
E
sta
blish
po
pu
latio
n b
ase
d d
elive
ry
me
ch
an
ism
(in
clu
din
g m
on
ito
rin
g s
yste
m),
pro
vid
ing
tra
inin
g,
tech
nic
al &
ma
teri
al su
pp
ort
3.3
.3
Nu
mb
er
of
inte
r se
cto
r te
ch
nic
al
co
nsu
lta
tio
ns h
eld
3.3
.4
Fo
rum
on
fo
od
pre
se
rva
tio
n
tech
niq
ue
s e
sta
blish
ed
3.4
.1
Re
se
arc
h c
on
du
cte
d &
fin
din
gs
dis
se
min
ate
d
3.4
.2
Ke
y m
essa
ge
s d
eve
lop
ed
&
dis
se
min
ate
d
3.5
.1
Cu
rric
ula
& t
rain
ing
pla
n
de
ve
lop
ed
& im
ple
me
nte
d
3.5
.2
80
% p
reg
na
nt
an
d la
cta
tin
g
wo
me
n a
tte
nd
ing
MC
H r
ece
ive
nu
tritio
n c
ou
nse
llin
g
3.5
.3
Tri
als
co
nd
ucte
d &
de
live
ry
me
ch
an
ism
id
en
tifie
d
3.5
.4
De
live
ry m
ech
an
ism
esta
blish
ed
Re
po
rts
Re
po
rts
Re
se
arc
h r
ep
ort
do
cu
me
nta
tio
n
Da
ta b
ase
on
tra
ine
d
pe
rso
nn
el
HM
IS
Tri
al re
po
rts
Activity r
ep
ort
s
co
ntr
ary
to
tra
ditio
na
l b
elie
fs
Ag
ricu
ltu
re a
nd
liv
elih
oo
ds
se
cto
r re
ce
ptive
to
co
lla
bo
ratio
n
Co
mm
un
ity w
illin
g t
o s
ha
re
kn
ow
led
ge
an
d in
form
atio
n
Ta
rge
t a
ud
ien
ce
re
ce
ptive
to n
ew
me
ssa
ge
s e
ve
n if
co
ntr
ary
to
tra
ditio
na
l b
elie
fs
MC
H s
taff
mo
tiva
ted
to
pro
vid
e c
ou
nse
llin
g
Pre
gn
an
t &
la
cta
tin
g w
om
en
rece
ptive
to
co
un
se
llin
g
30 O
utc
om
e 4
Pro
jec
t d
es
cri
pti
on
Ind
ica
tors
S
ou
rce
of
ve
rifi
ca
tio
n
As
su
mp
tio
ns
Ou
tco
me
4:
Imp
rove
d a
va
ila
bility a
nd
co
ve
rag
e o
f m
icro
nu
trie
nts
an
d d
e-w
orm
ing
in
terv
en
tio
ns t
o t
he
po
pu
latio
n
8 I
ncre
asin
g t
ren
ds in
bi a
nn
ua
l
vita
min
A s
up
ple
me
nta
tio
n in
ch
ild
ren
6-5
9 m
on
ths,
an
d
de
wo
rmin
g c
ove
rag
e in
1-5
ye
ars
,
sch
oo
l a
ge
d c
hild
ren
, p
reg
na
nt
(no
t
1st t
rim
este
r) &
la
cta
tin
g w
om
en
Ba
se
lin
e c
ove
rag
e d
ata
fro
m M
icro
nu
trie
nt
su
rve
y
MIC
S,
FS
NA
U s
urv
ey
rep
ort
s
Acce
ss t
o f
un
ctio
nin
g h
ea
lth
se
rvic
es
Acce
ss t
o f
oo
d s
ecu
rity
Acce
ss t
o h
ea
lth
y e
nvir
on
me
nt
Ou
tpu
ts:
4.1
In
cre
ase
d a
va
ila
bility o
f fo
rtifie
d f
oo
d
4.2
Im
pro
ve
d a
cce
ss t
o a
nd
utilisa
tio
n o
f m
icro
nu
trie
nt
su
pp
lem
en
ts a
nd
fo
rtifie
d su
pp
lem
en
tary
fo
od
b
y
vu
lne
rab
le g
rou
ps,
inclu
din
g u
nd
er
five
s,
pre
gn
an
t
an
d l
acta
tin
g w
om
en
, th
rou
gh
he
alth
se
rvic
es a
nd
co
mm
un
ity b
ase
d d
elive
ry s
tra
teg
ies
4.1
a 2
0%
ce
rea
ls p
rovid
ed
as
hu
ma
nita
ria
n a
ssis
tan
ce
are
fort
ifie
d b
y e
nd
of
thir
d y
ea
r
4.1
b 2
0%
in
cre
ase
in
ava
ila
bility o
f
fort
ifie
d f
oo
d (
no
n h
um
an
ita
ria
n)
by
en
d o
f th
ird
ye
ar
4.2
a a
t le
ast
80
% a
cce
ssib
le
ch
ild
ren
6-5
9 m
on
ths r
ece
ive
d
bi-
an
nu
al V
ita
min
A t
hro
ug
h
CH
D
4.2
b 9
0%
ch
ild
ren
6 t
o 5
9 m
on
ths in
nu
tritio
n p
rog
ram
me
s r
ece
ive
d
vita
min
A d
ose
4.2
c 8
0 %
wo
me
n a
nd
ch
ild
ren
wh
o
acce
ss M
CH
se
rvic
es r
ece
ive
reco
mm
en
de
d m
ultip
le
mic
ron
utr
ien
t su
pp
lem
en
tatio
n
4.2
d N
um
be
r o
f p
reg
na
nt
an
d
lacta
tin
g w
om
en
wh
o r
ece
ive
d
mu
ltip
le m
icro
nu
trie
nt
WF
P d
ata
WF
P d
ata
on
im
po
rts
CH
D r
ep
ort
s/F
SN
AU
nu
tritio
n s
urv
ey r
ep
ort
s
Imp
lem
en
tin
g p
art
ne
r
rep
ort
s
HM
IS
MIC
S
Pro
gra
mm
e d
ata
Co
mm
un
ity w
illin
g t
o a
cce
pt
fort
ifie
d
foo
d
Se
cu
rity
situ
atio
n a
llo
ws a
cce
ss f
or
imp
lem
en
tatio
n a
nd
utilisa
tio
n o
f
se
rvic
es
Mic
ron
utr
ien
t su
pp
lem
en
ts &
fo
rtifie
d
su
pp
lem
en
tary
fo
od
acce
pta
ble
to
targ
et
po
pu
latio
ns
Ta
rge
t p
op
ula
tio
ns c
om
ply
with
su
pp
lem
en
tatio
n r
eg
ime
31
4.3
In
cre
ase
d c
ove
rag
e o
f d
e-w
orm
ing
th
rou
gh
po
pu
latio
n-b
ase
d d
elive
ry m
ech
an
ism
s:
a)
Ch
ild
He
alth
Da
ys,
b)
sch
oo
ls,
c)
MC
H s
erv
ice
s a
nd
d)
nu
tritio
n p
rog
ram
me
s
su
pp
lem
en
tatio
n t
hro
ug
h
co
mm
un
ity b
ase
d d
elive
ry
me
ch
an
ism
4.2
e 9
5%
of
targ
ete
d b
en
eficia
rie
s
rece
ive
d f
ort
ifie
d
su
pp
lem
en
tary
fo
od
4.3
a
>8
0%
acce
ssib
le c
hild
ren
ag
ed
1 t
o 5
ye
ars
re
ce
ivin
g
de
wo
rmin
g t
hro
ug
h C
HD
4.3
b
70
% c
hild
ren
att
en
din
g
sch
oo
l re
ce
ive
de
-wo
rmin
g
4.3
c
40
% e
lig
ible
pre
gn
an
t (n
ot
1st
trim
este
r)a
nd
la
cta
tin
g
wo
me
n a
tte
nd
ing
MC
H
rece
ive
de
wo
rmin
g
4.3
d
90
% e
lig
ible
nu
tritio
n
pro
gra
mm
e b
en
eficia
rie
s
rece
ivin
g d
e-w
orm
ing
Imp
lem
en
tin
g p
art
ne
rs
rep
ort
s
Pro
gra
mm
e e
va
lua
tio
n
da
ta
CH
D r
ep
ort
s
Sch
oo
l re
po
rts o
f d
e-
wo
rmin
g a
ctivitie
s/
pro
gra
mm
e r
ep
ort
s
HM
IS
Imp
lem
en
tin
g p
art
ne
r
rep
ort
s
Activitie
s:
4.1
.1
Fo
rm a
fo
od
fo
rtific
atio
n s
ub
wo
rkin
g g
rou
p o
f
the
nu
tritio
n c
luste
r, w
ith
de
fin
ed
TO
Rs a
nd
me
mb
ers
hip
4.1
.2
Co
mm
issio
n f
oo
d f
ort
ific
atio
n e
xp
ert
fo
r p
eri
od
of
6 m
on
ths
4.1
.3
By e
nd
of
firs
t ye
ar,
co
nd
uct
fea
sib
ility s
tud
y o
f
ho
w f
ort
ific
atio
n o
f ce
rea
l flo
urs
fo
r
hu
ma
nita
ria
n f
oo
d a
ssis
tan
ce
ca
n b
e im
pro
ve
d,
inclu
din
g t
he
de
fin
itio
n o
f ta
rge
ts t
o b
e
ach
ieve
d o
ve
r su
bse
qu
en
t tw
o y
ea
rs
4.1
.4
P
ilo
t p
roje
ct
of
inclu
sio
n o
f fo
rtifie
d c
ere
al flo
urs
in h
um
an
ita
ria
n a
ssis
tan
ce
ge
ne
ral fo
od
ra
tio
n
4.1
.1 F
oo
d f
ort
ific
atio
n s
ub
wo
rkin
g
gro
up
is f
orm
ed
an
d m
ee
ts r
eg
ula
rly
4.1
.2 E
xp
ert
is c
om
mis
sio
ne
d
4.1
.3 F
ea
sib
ility s
tud
y c
on
du
cte
d &
targ
ets
de
fin
ed
4.1
.4
10
0%
ta
rge
ted
po
pu
latio
n
rece
ivin
g f
ort
ifie
d c
ere
al
TO
Rs
Me
etin
g r
ep
ort
s
Re
po
rt
Imp
lem
en
tin
g a
ge
ncie
s
rep
ort
s
Su
ita
ble
ca
nd
ida
te a
va
ila
ble
Su
ffic
ien
t su
pp
lie
s a
nd
lo
gis
tic s
up
po
rt
32 co
nd
ucte
d f
or
a s
pe
cific
ta
rge
t p
op
ula
tio
n
de
fin
ed
by n
utr
itio
n &
fo
od
aid
clu
ste
rs
4.1
.5
De
ve
lop
a f
ram
ew
ork
an
d a
ctio
n p
lan
, in
clu
din
g
reg
ula
tory
me
ch
an
ism
, fo
r th
e f
ort
ific
atio
n o
f
imp
ort
ed
fo
od
th
rou
gh
en
ga
gin
g w
ith
na
tio
na
l
an
d lo
ca
l a
uth
ori
tie
s a
nd
pri
va
te s
ecto
r
4.1
.6
Imp
lem
en
t a
ctio
n p
lan
fo
r fo
rtific
atio
n o
f
imp
ort
ed
fo
od
4.1
.7
Exp
lore
th
e p
ote
ntia
l fo
r fo
rtific
atio
n o
f lo
ca
l
ava
ilab
le f
oo
d t
hro
ug
h e
ng
ag
ing
with
lo
ca
l a
nd
na
tio
na
l a
uth
ori
tie
s a
nd
pri
va
te s
ecto
r d
uri
ng
ye
ar
1
4.1
.8
Co
nd
uct
inve
stig
atio
n in
to io
din
e s
itu
atio
n in
co
un
try
4.2
.1
Pro
vid
e t
rain
ing
, su
pp
lies a
nd
mo
nito
rin
g in
pu
t
to im
pro
ve
dis
trib
utio
n o
f vita
min
A
su
pp
lem
en
ts t
o a
ll ch
ildre
n 6
-5
9 m
on
ths
thro
ug
h b
i-a
nn
ua
l ch
ild h
ea
lth
da
ys
4.2
.2
D
eve
lop
sim
ple
So
ma
lia s
pe
cific
sta
nd
ard
ise
d
pro
toco
ls f
or
mic
ron
utr
ien
t su
pp
lem
en
tatio
n f
or
pre
gn
an
t &
la
cta
tin
g w
om
en
4.2
.3
D
eve
lop
an
d im
ple
me
nt
cu
rric
ula
an
d t
rain
ing
pla
n f
or
CH
W a
nd
MC
H s
taff
on
mic
ron
utr
ien
t
su
pp
lem
en
tatio
n
4.2
.4
P
rovid
e m
icro
nu
trie
nt
su
pp
lem
en
tatio
n s
up
plie
s
on
tim
ely
ba
sis
4.2
.5
M
CH
sta
ff p
rovid
e a
pp
rop
ria
te m
icro
nu
trie
nt
su
pp
lem
en
tatio
n a
t a
nte
na
tal a
nd
po
st
na
tal
vis
its
flo
urs
in
hu
ma
nita
ria
n
assis
tan
ce
ge
ne
ral fo
od
ratio
n
4.1
.5
Fra
me
wo
rk,
actio
n p
lan
an
d
reg
ula
tory
me
ch
an
ism
de
ve
lop
ed
4.1
.6
95
% a
ctio
n p
oin
ts o
f p
lan
imp
lem
en
ted
4.1
.7
Po
ten
tia
l fo
r lo
ca
l fo
rtific
atio
n
is d
efin
ed
4.1
.8 I
nve
stig
atio
n is c
on
du
cte
d
4.2
.1a
> 9
0%
CH
D w
ork
ers
tra
ine
d,
4.2
.1b
>9
0%
re
qu
ire
d s
up
plie
s
pro
vid
ed
4.2
.1c >
95
% m
on
ito
rin
g t
arg
ets
me
t
4.2
.2
sta
nd
ard
ise
d p
roto
co
l
de
ve
lop
ed
4.2
.3
Nu
mb
er
of
CH
W a
nd
MC
H
sta
ff t
rain
ed
on
mic
ron
utr
ien
t
su
pp
lem
en
tatio
n
4.2
.4
Nu
mb
er
of
da
ys s
tock o
uts
4.2
.5
80
% p
reg
na
nt
an
d la
cta
tin
g
wo
me
n a
tte
nd
ing
MC
H
rece
ivin
g m
icro
nu
trie
nt
su
pp
lem
en
tatio
n
Do
cu
me
nta
tio
n
Re
vie
w o
f a
ctivitie
s
Re
po
rt
Do
cu
me
nta
tio
n
CH
D e
va
lua
tio
n r
ep
ort
s
Do
cu
me
nta
tio
n
Ne
w d
ata
ba
se
on
tra
inin
g
rece
ive
d b
y h
ea
lth
wo
rke
rs
HM
IS
HM
IS
Will
ing
ne
ss o
f p
riva
te s
ecto
r to
en
ga
ge
an
d c
o-o
pe
rate
Fin
an
cia
l a
nd
ma
teri
al re
so
urc
es
ava
ilab
le
Inte
rest
an
d s
up
po
rt in
fo
od
fo
rtific
atio
n
fro
m lo
ca
l a
nd
na
tio
na
l a
uth
ori
tie
s
CH
D w
ork
ers
mo
tiva
ted
He
alth
wo
rke
rs m
otiva
ted
to
pro
vid
e
mic
ron
utr
ien
t su
pp
lem
en
tatio
n
Su
ffic
ien
t re
so
urc
es &
eff
icie
nt
log
istica
l
su
pp
ort
ava
ilab
le
Institu
tio
ns/g
rou
ps id
en
tifie
d w
illin
g a
nd
acce
ptin
g o
f in
vo
lve
me
nt
33
4.2
.6
Co
nd
uct
tria
ls t
o id
en
tify
in
no
va
tive
po
pu
latio
n
ba
se
d d
eliv
ery
me
ch
an
ism
s f
or
mu
ltip
le
mic
ron
utr
ien
t su
pp
lem
en
tatio
n t
o w
om
en
of
rep
rod
uctive
ag
e
4.2
.7
Ba
se
d o
n t
ria
ls,
sca
le u
p p
op
ula
tio
n b
ase
d
de
live
ry m
ech
an
ism
fo
r m
ultip
le m
icro
nu
trie
nt
su
pp
lem
en
tatio
n,
inclu
din
g p
roto
co
l
de
ve
lop
me
nt,
tra
inin
g,
su
pp
lies a
nd
mo
nito
rin
g
syste
m
4.2
.8
Co
nd
uct
fea
sib
ility
stu
dy o
f h
om
e f
ort
ific
atio
n
pro
du
cts
, d
efin
ing
ta
rge
ts a
nd
actio
n p
lan
fo
r
su
bse
qu
en
t im
ple
me
nta
tio
n
4.2
.9
Imp
lem
en
t a
ctio
n p
lan
on
ho
me
fo
rtific
atio
n
pro
du
cts
acco
rdin
g t
o f
ea
sib
ility
stu
dy
reco
mm
en
da
tio
ns
4.2
.10
D
istr
ibu
te f
ort
ifie
d s
up
ple
me
nta
ry f
oo
ds t
o
vu
lne
rab
le g
rou
ps in
se
lecte
d h
igh
ris
k a
rea
s
as d
efin
ed
by n
utr
itio
n c
luste
r
4.3
.1
Pro
vid
e t
rain
ing
, su
pp
lies a
nd
mo
nito
rin
g i
np
ut
for
de
wo
rmin
g to
b
i a
nn
ua
l C
HD
s &
n
utr
itio
n
pro
gra
mm
es
4.3
.2
De
ve
lop
sim
ple
, S
om
ali
sp
ecific
pro
toco
l fo
r
de
wo
rmin
g in
sch
oo
ls,
inclu
din
g s
yste
m f
or
mo
nito
rin
g &
eva
lua
tio
n
4.3
.3
Pro
vid
e t
ech
nic
al (W
HO
) &
lo
gis
tica
l (W
FP
)
su
pp
ort
to
sch
oo
ls d
ew
orm
ing
pro
gra
mm
e
4.3
.4
De
ve
lop
sim
ple
pro
toco
l fo
r d
ew
orm
ing
of
pre
gn
an
t &
la
cta
tin
g w
om
en
an
d c
hild
ren
1-5
ye
ars
at
MC
H f
acili
tie
s &
He
ath
po
sts
, a
ime
d a
t
4.2
.6
Po
pu
latio
n b
ase
d d
eliv
ery
me
ch
an
ism
id
en
tifie
d b
y e
nd
of
ph
ase
1
4.2
.7
De
live
ry m
ech
an
ism
fo
r
mu
ltip
le m
icro
nu
trie
nt
su
pp
lem
en
tatio
n is
esta
blis
he
d in
se
lecte
d
are
as,
by e
nd
ph
ase
2
4.2
.8
Fe
asib
ility
stu
dy is
co
nd
ucte
d,
targ
ets
se
t,
actio
n p
lan
de
fin
ed
, b
y e
nd
of
ph
ase
1
4.2
.9
Actio
n p
lan
im
ple
me
nte
d in
se
lecte
d a
rea
s,
by e
nd
of
ph
ase
2
4.2
.10
75
% t
arg
ete
d b
en
eficia
rie
s
rea
ch
ed
4.3
.1a
9
5%
CH
D w
ork
ers
tra
ine
d,
4.3
.1b
95
% r
eq
uir
ed
su
pp
lies
pro
vid
ed
4.3
.1c 9
5%
mo
nito
rin
g t
arg
ets
me
t
4.3
.2 a
) P
roto
co
l is
de
ve
lop
ed
b)
incre
asin
g t
ren
ds in
x%
sch
oo
ls
imp
lem
en
tin
g p
roto
co
l9
4.3
.3 9
0%
ta
rge
ted
sch
oo
ls r
ece
ive
de
fin
ed
su
pp
ort
4.3
.4a
Pro
toco
l is
de
ve
lop
ed
4.3
.4b
in
cre
asin
g t
ren
ds in
x%
he
alth
fa
cili
tie
s im
ple
me
ntin
g
Activity r
ep
ort
s
Tri
al re
po
rts
Imp
lem
en
tin
g a
ge
ncie
s
rep
ort
s
Stu
dy r
ep
ort
Activity r
ep
ort
s
Imp
lem
en
tin
g a
ge
ncie
s
rep
ort
s
CH
D &
nu
tritio
n
pro
gra
mm
e r
ep
ort
s
Do
cu
me
nta
tio
n
Sch
oo
l, W
HO
, W
FP
rep
ort
s
Do
cu
me
nta
tio
n
Fa
cili
ty s
urv
ey d
ata
Su
ffic
ien
t re
so
urc
es &
eff
icie
nt
log
istica
l
su
pp
ort
ava
ilab
le
Ta
rge
ted
be
ne
ficia
rie
s w
illin
g t
o u
se
ne
w m
ech
an
ism
Ho
me
fo
rtific
atio
n p
rod
ucts
acce
pta
ble
to b
en
eficia
rie
s
Ta
rge
ted
be
ne
ficia
rie
s u
se
su
pp
lem
en
tary
fo
od
s a
s in
str
ucte
d
CH
D &
nu
tritio
n p
rog
ram
me
wo
rke
rs
mo
tiva
ted
to
pro
vid
e d
ew
orm
ing
Sch
oo
ls r
ece
ptive
an
d w
illin
g t
o
imp
lem
en
t d
ew
orm
ing
He
alth
sta
ff m
otiva
ted
to
im
ple
me
nt
pro
toco
l
Su
ffic
ien
t su
pp
lies a
nd
eff
icie
nt
log
istica
l su
pp
ort
34
red
ucin
g m
isse
d o
pp
ort
un
itie
s
4.3
.5
Pro
vid
e t
rain
ing
& t
ime
ly s
up
plie
s t
o C
HW
&
MC
H s
taff
fo
r e
ffe
ctive
im
ple
me
nta
tio
n o
f
de
wo
rmin
g p
roto
co
l
de
wo
rmin
g p
roto
co
l10
4.3
.5a
Nu
mb
er
of
he
alth
sta
ff
tra
ine
d a
nd
active
on
de
wo
rmin
g
4.3
.5b
Nu
mb
er
of
da
ys o
f sto
ck o
uts
of
de
wo
rmin
g d
rug
s
Ne
w d
ata
ba
se
on
tra
inin
g
of
he
alth
wo
rke
rs
HM
IS S
up
ply
da
ta
35 O
utc
om
e 5
Pro
jec
t d
es
cri
pti
on
Ind
ica
tors
S
ou
rce
of
ve
rifi
ca
tio
n
As
su
mp
tio
ns
Ou
tco
me
5:
Imp
rove
d m
ain
str
ea
min
g o
f n
utr
itio
n a
s a
ke
y
co
mp
on
en
t o
f h
ea
lth
an
d o
the
r re
leva
nt
se
cto
rs
70
% h
ea
lth
, W
AS
H,
live
lih
oo
d,
ed
uca
tio
n a
nd
fo
od
aid
CA
P
pro
jects
in
clu
de
nu
tritio
n in
dic
ato
rs
50
% o
f h
ea
lth
, W
AS
H,
Liv
elih
oo
d,
ed
uca
tio
n s
ecto
r p
roje
cts
in
clu
de
nu
tritio
n a
ctivitie
s
Nu
tritio
n a
ctivitie
s/o
utc
om
es a
re
inclu
de
d in
UN
SA
S
CA
P r
evie
w
3W
s o
f se
cto
r clu
ste
rs
an
d w
ork
ing
gro
up
s
UN
SA
S r
evie
w
Ou
tpu
ts:
5.1
Nu
tritio
n is e
ffe
ctive
ly in
co
rpo
rate
d in
to t
he
po
licie
s,
str
ate
gie
s,
activitie
s,
de
live
ry
me
ch
an
ism
s
an
d
ou
tco
me
s o
f h
ea
lth
se
cto
r
5.1
a n
um
be
r o
f re
leva
nt
he
alth
se
cto
r p
olicie
s e
tc in
clu
din
g n
utr
itio
n
ind
ica
tors
5.1
b 6
0%
11 w
om
en
an
d c
hild
ren
att
en
din
g M
CH
se
rvic
es w
ho
rece
ive
ap
pro
pri
ate
nu
tritio
n
scre
en
ing
, n
utr
itio
n c
ou
nse
llin
g &
mic
ron
utr
ien
t tr
ea
tme
nt
or
su
pp
lem
en
tatio
n b
y e
nd
of
firs
t
ph
ase
, in
cre
asin
g t
o 8
0%
by e
nd
of
ph
ase
2
5.1
c >
80
% t
arg
ete
d b
en
eficia
rie
s o
f
CH
D r
ece
ivin
g v
ita
min
A,
nu
tritio
n
scre
en
ing
& d
ew
orm
ing
5.1
d N
utr
itio
n in
terv
en
tio
ns a
re
inclu
de
d a
s c
ore
co
mp
on
en
t in
Re
vie
w o
f p
olicy,
str
ate
gy a
ctivity
do
cu
me
nts
HM
IS
CH
D e
va
lua
tio
n r
ep
ort
s
Re
vie
w o
f p
olicie
s a
nd
pro
gra
mm
es
Willin
gn
ess o
f o
the
r se
cto
rs t
o
co
lla
bo
rate
36 5
.2 N
utr
itio
n is
in
teg
rate
d in
to th
e p
olicie
s,
str
ate
gie
s,
activitie
s,
de
live
ry
me
ch
an
ism
s
an
d
ou
tco
me
s
of
WA
SH
, live
lih
oo
ds,
ed
uca
tio
n a
nd
fo
od
aid
se
cto
rs
ma
na
ge
me
nt
of
rele
va
nt
co
mm
un
ica
ble
an
d n
on
co
mm
un
ica
ble
dis
ea
se
s e
g T
B,
HIV
, m
ala
ria
, m
en
tal h
ea
lth
5.2
a W
AS
H
50
% o
f re
leva
nt
WA
SH
inte
rve
ntio
ns in
clu
de
nu
tritio
n
ind
ica
tors
as m
ea
su
re o
f im
pa
ct
75
% n
utr
itio
n p
rog
ram
me
s
de
live
rin
g g
oo
d h
yg
ien
e p
rom
otio
n
activitie
s
5.2
b A
gri
cu
ltu
re/L
ive
lih
oo
ds
70
% r
ele
va
nt
pro
jects
in
co
rpo
ratin
g
nu
tritio
n in
dic
ato
rs a
s o
utc
om
e
ind
ica
tors
,
70
% r
ele
va
nt
pro
jects
use
nu
tritio
n
sta
tus f
or
targ
etin
g in
terv
en
tio
ns
70
% r
ele
va
nt
pro
jects
in
clu
de
nu
tritio
n e
du
ca
tio
n a
s a
su
pp
ort
ing
activity
5.2
c E
du
ca
tio
n
70
% s
ch
oo
ls p
rovid
e n
utr
itio
n
ed
uca
tio
n a
s p
art
of
reg
ula
r
cu
rric
ulu
m
Re
vie
w o
f p
olicie
s a
nd
pro
jects
Re
vie
w o
f p
olicie
s a
nd
pro
jects
Re
vie
w o
f cu
rric
ula
Sch
oo
l re
po
rts
Willin
gn
ess o
f h
ea
lth
se
cto
r to
co
lla
bo
rate
Su
ffic
ien
t re
so
urc
es a
va
ila
ble
Activitie
s:
5.1
.1
Fo
ste
r im
pro
ve
d
inte
rse
cto
ral
co
lla
bo
ratio
n
&
de
fin
e p
rio
rity
are
as f
or
pa
rtn
ers
hip
5.1
.1a
nu
mb
er
of
inte
rse
cto
ral
co
nsu
lta
tio
n m
ee
tin
gs h
eld
5.1
.1b
x%
att
en
da
nce
at
se
cto
r
clu
ste
r m
ee
tin
gs
12
Me
etin
g r
ep
ort
s
Willin
gn
ess o
f o
the
r se
cto
rs t
o
co
lla
bo
rate
37
5.1
.2
Esta
blish
m
ech
an
ism
fo
r te
ch
nic
al
nu
tritio
n
inp
ut
into
re
leva
nt
me
etin
gs,
revie
ws
5.1
.3
Pro
vid
e
ne
ce
ssa
ry
inp
uts
(f
un
din
g,
tra
inin
g,
su
pp
lie
s,
mo
nito
rin
g)
to
imp
rove
q
ua
lity
o
f
nu
tritio
n
se
rvic
es
de
live
red
th
rou
gh
C
HD
s,
acco
rdin
g t
o d
efin
ed
ta
rge
ts
5.1
.4
Pro
vid
e
ne
ce
ssa
ry
inp
uts
to
im
pro
ve
q
ua
lity
an
d
co
ve
rag
e
of
nu
tritio
n
se
rvic
es
de
live
red
thro
ug
h h
ea
lth
fa
cilitie
s (
sta
nd
ard
ise
d g
uid
elin
es
an
d
pro
toco
ls
for
nu
tritio
n
activitie
s,
su
pp
lie
s,
co
mp
reh
en
siv
e t
rain
ing
fo
r h
ea
lth
fa
cility s
taff
)
5.1
.5
Co
nd
uct
ma
pp
ing
of
are
as w
ith
po
or
acce
ss t
o
he
alth
se
rvic
es
5.1
.6
Ad
vo
ca
te
in
loca
tio
ns
wh
ere
a
va
ila
bility
of
he
alth
se
rvic
es
is
a
lim
itin
g
facto
r fo
r o
ptim
al
nu
tritio
n
5.1
.7
Co
nd
uct
se
nsitis
atio
n
on
n
utr
itio
n
as
de
term
ina
nt
of
he
alth
a
nd
d
eve
lop
me
nt
am
on
g
lin
e
min
istr
ies
an
d
ad
vo
ca
te
for
inclu
sio
n
of
nu
tritio
n
inte
rve
ntio
ns
as
co
re
co
mp
on
en
t o
f
pu
blic s
erv
ice
s
5.2
.1
Fo
ste
r in
ters
ecto
ral
co
lla
bo
ratio
n
an
d
de
fin
e
pri
ori
ty a
rea
s fo
r p
art
ne
rsh
ip w
ith
e
ach
se
cto
r
(eg
a
gri
cu
ltu
re/liv
elih
oo
ds-
imp
rovin
g
die
tary
div
ers
ity,
WA
SH
: B
CC
- in
teg
ratin
g p
rom
otio
n o
f
op
tim
al
nu
tritio
n a
nd
g
oo
d h
yg
ien
e p
ractice
s,
ed
uca
tio
n-
inte
gra
tin
g
nu
tritio
n
ed
uca
tio
n
into
sch
oo
l cu
rric
ula
)
5.1
.2 m
ech
an
ism
esta
blish
ed
5.1
.3 9
0%
in
pu
ts p
rovid
ed
,
acco
rdin
g t
o d
efin
ed
ta
rge
ts
5.1
.4a
x%
he
alth
fa
cilitie
s u
sin
g
sta
nd
ard
ise
d
gu
ide
lin
es/p
roto
co
ls13
5.1
.4b
Nu
mb
er
of
da
ys s
tock o
uts
of
nu
tritio
n s
up
plie
s
5.1
.4c x
% h
ea
lth
fa
cility s
taff
rece
ive
d n
utr
itio
n t
rain
ing
14
5.1
.5 M
ap
pin
g c
on
du
cte
d a
nd
do
cu
me
nte
d
5.1
.6 N
um
be
r o
f a
dvo
ca
cy m
ee
tin
gs
he
ld
5.1
.7
Nu
mb
er
of
me
etin
gs h
eld
to
dis
cu
ss n
utr
itio
n w
ith
lin
e
min
istr
ies
5.2
.1a
nu
mb
er
of
inte
rse
cto
ral
co
nsu
lta
tio
n m
ee
tin
gs h
eld
,
5.2
.1b
x%
att
en
da
nce
at
se
cto
r
clu
ste
r m
ee
tin
gs
15
5.2
.1c P
rio
rity
are
as d
efin
ed
Re
po
rts
CH
D e
va
lua
tio
n r
ep
ort
s
HM
IS
Fa
cility b
ase
d s
urv
ey
HM
IS S
up
ply
da
ta
Da
tab
ase
on
tra
ine
d
he
alth
pe
rso
nn
el
Re
po
rts
Me
etin
g r
ep
ort
s
Me
etin
g r
ep
ort
s
Re
po
rts
Su
ffic
ien
t su
pp
lie
s &
lo
gis
tica
l
su
pp
ort
to
im
ple
me
nt
CH
Ds
eff
ective
ly
He
alth
fa
cility s
taff
mo
tiva
ted
to
imp
lem
en
t n
utr
itio
n a
ctivitie
s
Se
cto
r o
pe
n t
o a
dvo
ca
cy
Su
ffic
ien
t re
so
urc
es a
va
ila
ble
Willin
gn
ess o
f o
the
r se
cto
rs t
o
co
lla
bo
rate
38
5.2
.2
Esta
blis
h a
m
ech
an
ism
fo
r te
ch
nic
al
nu
tritio
n
inp
ut
into
re
leva
nt
pro
ce
ss
5.2
.3
Pro
vid
e t
ech
nic
al
inp
ut,
tra
inin
g a
nd
ma
teri
als
for
imp
rovin
g n
utr
itio
n co
mp
on
en
t o
f re
leva
nt
se
cto
r p
rog
ram
min
g,
acco
rdin
g
to
ag
ree
d
targ
ets
5.2
.4
Co
nd
uct
ma
pp
ing
of
are
as w
ith
po
or
acce
ss t
o
WA
SH
/ a
gri
cu
ltu
re/liv
elih
oo
ds/e
du
ca
tio
n
/fo
od
aid
se
rvic
es
5.2
.5
Ad
vo
ca
te
in
loca
tio
ns
wh
ere
a
va
ilab
ility
o
f
WA
SH
/ag
ricu
ltu
re/liv
elih
oo
ds/e
du
ca
tio
n/f
oo
d
aid
se
rvic
es
are
a
lim
itin
g
facto
r fo
r o
ptim
al
nu
tritio
n
5.2
.2 M
ech
an
ism
esta
blis
he
d
5.2
.3a
Nu
mb
er
of
tech
nic
al
co
nsu
lta
tio
ns h
eld
5.2
.3b
>9
0%
ag
ree
d m
ate
ria
ls
su
pp
lied
5.2
.3c 9
0%
ag
ree
d t
rain
ing
s h
eld
5.2
.4
Ma
pp
ing
co
nd
ucte
d
5.2
.5 N
um
be
r o
f a
dvo
ca
cy m
ee
tin
gs
he
ld
Re
po
rt
Co
nsu
lta
tio
n r
ep
ort
s
Pro
gra
mm
e r
ep
ort
s
Pro
gra
mm
e r
ep
ort
s
Do
cu
me
nta
tio
n
Me
etin
g r
ep
ort
s
39
Ou
tco
me
6
Pro
jec
t d
es
cri
pti
on
Ind
ica
tors
S
ou
rce
of
ve
rifi
ca
tio
n
As
su
mp
tio
ns
Ou
tco
me
6:
Imp
rove
d c
ap
acity a
nd
me
an
s in
co
un
try t
o d
eliv
er
esse
ntia
l n
utr
itio
n s
erv
ice
s
Fe
ed
ing
pro
gra
mm
e p
erf
orm
an
ce
ind
ica
tors
as a
me
asu
re o
f ca
pa
city
of
LN
GO
s t
o d
eliv
er
tre
atm
en
t
Incre
asin
g t
ren
d in
nu
mb
er
of
Mo
H
pe
rso
nn
el tr
ain
ed
in
nu
tritio
n
Incre
asin
g t
ren
d in
nu
mb
er
he
alth
facili
tie
s w
ith
pe
rso
nn
el tr
ain
ed
in
nu
tritio
n
Activitie
s o
f lo
ca
l e
sta
blis
he
d
str
uctu
re –
de
ve
lop
se
t o
f
pe
rfo
rma
nce
in
dic
ato
rs a
s p
art
of
TO
Rs
UN
ICE
F d
ata
ba
se
Mo
H r
ep
ort
s
Da
tab
ase
on
he
alth
wo
rke
rs a
nd
tra
inin
g
rece
ive
d
Activity r
ep
ort
s
Se
cu
rity
situ
atio
n a
llow
s d
eliv
ery
of
se
rvic
es
Ou
tpu
ts:
6.1
A tw
o ye
ar
nu
tritio
n se
cto
r ca
pa
city d
eve
lop
me
nt
str
ate
gy a
nd
pla
n o
f a
ctio
n is d
eve
lop
ed
jo
intly w
ith
loca
l a
uth
ori
tie
s b
y t
he
en
d o
f 2
01
1
6.2
Ca
pa
city
de
ve
lop
me
nt
an
d
tra
inin
g
activitie
s
are
imp
lem
en
ted
acco
rdin
g t
o p
lan
of
actio
n
6.3
Re
gio
na
l tr
ain
ing
a
nd
m
en
tori
ng
ce
lls a
re fo
rme
d
by t
he
en
d o
f 2
01
1.
6.4
In
tern
atio
na
lly
reco
gn
ise
d
tra
inin
g
gu
ide
line
s
an
d
pro
toco
ls a
re a
da
pte
d t
o t
he
So
ma
li co
nte
xt
6.5
An
e
na
blin
g
en
vir
on
me
nt
for
all
sta
ke
ho
lde
rs
to
6.1
Str
ate
gy a
nd
actio
n p
lan
is
de
ve
lop
ed
6.2
x%
of
activitie
s d
efin
ed
in
actio
n
pla
n a
re im
ple
me
nte
d1
6
6.3
Ce
lls a
re e
sta
blis
he
d
6.4
a 9
0%
of
rele
va
nt
gu
ide
line
s a
nd
pro
toco
ls a
da
pte
d t
o S
om
ali
co
nte
xt
6.4
b 8
0%
pa
rtn
ers
usin
g a
da
pte
d
gu
ide
line
s b
y e
nd
ph
ase
2
Re
po
rts
Pu
blis
he
d s
tra
teg
y
Re
po
rts
Re
vie
w o
f d
ocu
me
nts
Pa
rtn
ers
re
po
rts
Sta
ke
ho
lde
r re
po
rts
He
alth
au
tho
ritie
s,
line
min
istr
ies
are
su
pp
ort
ive
an
d p
rovid
e
ne
ce
ssa
ry c
on
ditio
ns f
or
imp
lem
en
tatio
n
Re
so
urc
es f
or
ca
pa
city
de
ve
lop
me
nt
str
ate
gy a
re
fort
hco
min
g
Ne
w t
rain
ing
& m
en
tori
ng
ce
lls
acce
pte
d a
nd
giv
en
su
ffic
ien
t
ma
nd
ate
imp
lem
en
t q
ua
lity
nu
tritio
n p
rog
ram
me
s i
s c
rea
ted
an
d
su
sta
ine
d
in
co
lla
bo
ratio
n
with
th
e
loca
l
au
tho
ritie
s
6.5
90
% o
f ta
rge
ted
sta
ke
ho
lde
rs
rece
ivin
g n
ece
ssa
ry
eq
uip
me
nt,
ma
teri
als
an
d
reso
urc
es,
acco
rdin
g t
o a
sta
nd
ard
ize
d a
nd
acce
pte
d lis
t
of
ma
teri
als
ie
co
mp
ute
r,
inte
rne
t co
nn
ectio
n,
ph
oto
co
pie
r e
tc.
an
d a
ge
ncie
s s
up
ply
da
ta
Su
ffic
ien
t re
so
urc
es a
va
ila
ble
Activitie
s:
6.1
.1
Esta
blish
str
ate
gy
de
ve
lop
me
nt
wo
rkin
g
gro
up
with
de
fin
ed
TO
Rs
6.1
.2
Ide
ntify
sco
pe
of
str
ate
gy
6.1
.3
En
su
re m
ulti fa
ce
ted
ap
pro
ach
to
de
ve
lop
me
nt
of
tech
nic
al
skills
–
h
an
ds o
n tr
ain
ing
, w
ork
sh
op
s,
dis
tan
ce
le
arn
ing
o
pp
ort
un
itie
s,
reg
ion
al
vis
its
an
d
wo
rksh
op
s,
ap
pro
pri
ate
n
utr
itio
n
tra
inin
g
inte
gra
ted
in
to
exis
tin
g
pre
-se
rvic
e
tra
inin
g
cu
rric
ula
6.1
.4
C
rea
te
lin
ks
with
re
gio
na
l tr
ain
ing
/me
nto
rin
g
ce
lls,
inte
rna
tio
na
l a
ca
de
mic
/tra
inin
g
institu
tio
ns
6.1
.5
Ad
vo
ca
te f
or
an
d id
en
tify
fu
nd
ing
of
str
ate
gy
6.2
.1
Pro
vid
e
ne
ce
ssa
ry
su
pp
ort
a
nd
in
pu
ts
for
imp
lem
en
tatio
n o
f p
lan
of
actio
n
6.3
.1
De
fin
e s
co
pe
an
d r
ole
of
reg
ion
al
tra
inin
g a
nd
me
nto
rin
g c
ells
6.3
.2
Esta
blish
le
ad
ers
hip
an
d m
em
be
rsh
ip
6.3
.3
Ide
ntify
ga
ps a
nd
tra
inin
g n
ee
ds
6.1
.1 W
ork
ing
gro
up
esta
blish
ed
&
TO
Rs
6.1
.2 S
co
pe
de
fin
ed
6.1
.3 M
ulti fa
ce
ted
ap
pro
ach
ad
op
ted
6.1
.4 n
um
be
r o
f lin
ks e
sta
blish
ed
6.1
.5 x
% f
un
din
g id
en
tifie
d1
7
6.2
.1 9
0%
in
pu
ts p
rovid
ed
acco
rdin
g t
o p
lan
of
actio
n
6.3
.1 T
OR
s d
efin
ed
& a
gre
ed
6.3
.2 L
ea
de
rsh
ip a
nd
me
mb
ers
hip
en
do
rse
d
6.3
.3 G
ap
s a
nd
tra
inin
g n
ee
ds
ide
ntifie
d
Do
cu
me
nta
tio
n
Do
cu
me
nta
tio
n
Re
vie
w o
f str
ate
gy
Do
cu
me
nta
tio
n
Do
cu
me
nta
tio
n
Do
cu
me
nta
tio
n
Ce
ll r
ep
ort
Ce
ll r
ep
ort
Do
cu
me
nta
tio
n
Activity r
ep
ort
s
Wo
rkin
g g
rou
p m
em
be
rs
mo
tiva
ted
Do
no
rs a
re r
ece
ptive
Su
ffic
ien
t re
so
urc
es a
va
ila
ble
He
alth
au
tho
ritie
s,
lin
e m
inis
trie
s
are
su
pp
ort
ive
an
d p
rovid
e
ne
ce
ssa
ry c
on
ditio
ns f
or
esta
blish
me
nt
of
ce
lls
Pa
rtn
ers
/ag
en
cie
s w
illin
g t
o
40
41
6.3
.4
De
ve
lop
a
nd
im
ple
me
nt
tra
inin
g
pla
n
an
d
cu
rric
ula
6.4
.1
Co
nstr
uct
an
in
ve
nto
ry
of
inte
rna
tio
na
lly
reco
gn
ise
d t
rain
ing
gu
ide
line
s a
nd
pro
toco
ls
6.4
.2
Ad
ap
t a
nd
tr
an
sla
te
the
m
ost
rele
va
nt
gu
ide
line
s &
pro
toco
ls t
o t
he
So
ma
li co
nte
xt
6.5
.1
Pro
vid
e
ne
ce
ssa
ry
tra
inin
g,
eq
uip
me
nt,
ma
teri
als
a
nd
re
so
urc
es
to
pa
rtn
ers
imp
lem
en
tin
g
nu
tritio
n
activitie
s,
inclu
din
g
Mo
H,
line
m
inis
trie
s,
LN
GO
s
an
d
co
mm
un
ity
institu
tio
ns
to
en
ab
le
the
m
to
imp
lem
en
t
nu
tritio
n
inte
rve
ntio
ns
acco
rdin
g
to
sta
nd
ard
ise
d g
uid
elin
es
6.3
.4a
cu
rric
ula
de
ve
lop
ed
by e
nd
ph
ase
1
6.3
.4b
80
% t
rain
ing
pla
n
imp
lem
en
ted
by e
nd
ph
ase
2
6.4
.1 in
ve
nto
ry c
om
plie
d
6.4
.2 9
0%
re
leva
nt
gu
ide
line
s &
pro
toco
ls a
da
pte
d &
tra
nsla
ted
6.5
.1 9
0%
re
so
urc
es p
rovid
ed
acco
rdin
g t
o g
uid
elin
es
Re
po
rt
Re
vie
w o
f d
ocu
me
nts
Su
pp
ly d
ata
acce
pt
an
d s
up
po
rt t
he
co
nce
pt
of
tra
inin
g a
nd
me
nto
rin
g c
ells
Ad
ap
tatio
ns a
re a
cce
pta
ble
an
d
ad
op
ted
by a
ge
ncie
s
Imp
lem
en
tin
g p
art
ne
r sta
ff
mo
tiva
ted
to
im
ple
me
nt
activitie
s
1 A
data
base
of
all
healt
h c
are
pro
vid
ers
an
d t
he t
rain
ing
th
ey
hav
e r
eceiv
ed
is
cu
rren
tly
bein
g d
ev
elo
ped
2 I
f in
clu
ded
in
th
e n
ew
MA
M g
uid
eli
nes
3 %
to
be c
on
firm
ed
4 %
to
be c
on
firm
ed
5 R
efe
ren
ce M
icro
nu
trie
nt
surv
ey
20
09
6 R
efe
ren
ce M
ICS
20
06
(re
vis
e a
fter
MIC
S 2
01
0)
7 R
efe
ren
ce M
icro
nu
trie
nt
Su
rvey
20
09
8 I
deall
y o
utc
om
e i
nd
icato
r w
ou
ld b
e i
mp
rov
ed
mic
ron
utr
ien
t st
atu
s o
f p
op
ula
tio
n,
red
uced
pre
vale
nce o
f an
aem
ia,
vit
am
in A
& i
od
ine d
efi
cie
ncy
bu
t 3
years
to
o s
ho
rt t
o
measu
re s
ign
ific
an
t ch
an
ges
& a
s y
et
no
pla
n f
or
rep
eat
mic
ron
utr
ien
t su
rvey
9 %
to
be c
on
firm
ed
1
0 %
to
be c
on
firm
ed
1
1 B
ase
d o
n E
PH
S f
or
So
mali
a 2
00
8
12 %
to
be c
on
firm
ed
1
3 %
to
be c
on
firm
ed
1
4 %
to
be c
on
firm
ed
1
5 %
to
be c
on
firm
ed
1
6 %
to
be c
on
firm
ed
1
7 %
to
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CONTENTS1. Background information 43
2. Current nutrition situation 43 2.1 Acute malnutrition . 43 2.2 Chronic malnutrition. 44 2.3 Trends in malnutrition 2001-2008 44 2.4 Micronutrient malnutrition 45
3. Determinants of malnutrition in Somalia 46 3.1 Food access and availability 46 3.2 Social and care environment . 49 3.3 Access to health services and a healthy environment 51 3.4 Education 52
4. Current Nutrition interventions 52 4.1 Nutrition Cluster approach 52 4.2 Food security and nutrition surveillance 53 4.3 Treatment of severe acute malnutrition 53 4.4 Treatment of moderate acute malnutrition 54 4.5 Prevention of moderate acute malnutrition 54 4.6 Institutional feeding and school feeding 54 4.7 General food distribution 54 4.8 Nutrition activities delivered through the health sector 55 4.9 Other sector activities with nutrition focus 55 4.10 SWOT analysis of current interventions 55
NUTRITION SITUATION ANALYSIS
ANNEX 2
43
1. Background InformationSomalia is populated by a resilient and highly independent people, whose nomadic tradition plays a major role in determining their collective persona. Clan-based Somali culture has evolved to survive in the harsh and arid environment of the Horn of Africa. Since the collapse of central government in 1991 and resulting civil war, there have been many efforts to restore a central government in Somalia without sustained success. In 1991 the North west zone (NWZ) declared the independent state of Somaliland. This independence has not been recognized by most other countries but Somaliland has remained at relative peace and stability since, with governing administration in the capital Hargesia. The North east Zone (NEZ) declared itself as the autonomous region of Puntland in 1998. Although governed by its administration in its capital Garowe, it pledges to participate in any Somali reconciliation and reconstruction process that should occur. In South Central Somalia political conflict and violence continue to prevail, despite attempts to establish and support a central governing entity.
The combination of conflict, insecurity, mass displacement, recurrent droughts and flooding and extreme poverty, coupled with very low basic social service coverage, has seriously affected food security and livelihoods and greatly increased vulnerability to disease and malnutrition. The MDG health-related indicators are among the worst in the world. Life expectancy is 45 years. One child in every twelve dies before the age of one year while, one child in seven dies before the age of five.
2. Current Nutrition SituationToday, almost all Somalis are affected by the fragile security environment, large-scale population displacements, food insecurity and lack of basic social and health services, with coping mechanisms stretched to the limit as families struggle to absorb these multiple shocks. The result is alarming rates of acute malnutrition and chronic malnutrition throughout the country with some variations by zone and livelihood system.
2.1 Acute malnutrition According to the most recent analysis from FSNAU, the Post Deyr ‘09/10 seasonal assessment, the national median rate of global acute malnutrition (GAM) was 16% based on WHO Growth Standards, compared to 19% for all 34 nutrition surveys conducted prior to the Post Gu 2009 assessment. The median rate of severe acute malnutrition (WHZ < 3 SD) was 4.2% compared to 4.5% Post Gu 2009. These current rates correspond to 1 in 6 (240,0001) children acutely malnourished (WHZ < 2 SD) of which 1 in 22 (63,000) children are suffering severe acute malnutrition with a 9 fold greater risk of early death than their well nourished counterparts. The FSNAU Post Gu assessment 2009 also estimated a further 84,000 pregnant women to be acutely malnourished, a condition which leads to poor intrauterine growth, low birth weight, stunting and developmental delay and predisposes to another generation of malnourished mothers perpetuating the intergenerational cycle of malnutrition.
Within the overall picture there are differences by zone and by livelihood system. Eighty one percent of the acutely malnourished children live in South and Central regions - the areas also affected most by insecurity and restricted humanitarian space. In Somaliland, rates of acute malnutrition are less critical but population density is high, meaning that in a relatively high proportion of total number of acutely malnourished children live there. This has important implications for the geographical coverage of interventions.
1 Caseload figures based on population figures from the UNDP 2005 settlement survey are used as the standard reference for Somalia
44 As highlighted by the Post Gu 2009 assessment and again in the more recent Post Deyr 09/10 assessment, Internally Displaced Populations (IDPs) continue to be the most nutritionally vulnerable, even those in the relative security of the northern regions. The median GAM rate among IDPs is 16.7% which is higher then the national rate, median SAM rate is 5.0% and the median stunting rate of 25% is the highest of all groups. Most IDPs in South Central Somalia are living in overpopulated camps with limited access to water, diversified food and adequate sanitation services. Furthermore, the influx of IDPs from the South to the northern areas has begun to strain already limited social services and create tensions with the local communities.
2.2 Chronic malnutrition The FSNAU Post Deyr 09/10 assessment found very high rates of stunting of 22% in the South Central Somalia compared to 14% in Somaliland and 11% in Puntland. The higher rates in South Central Somalia reflect the chronic volatile situation causing population displacements, lack of administration and public services and loss of livelihoods. This compares to the relative peace and stability in Somaliland.
2.3 Trends in malnutrition- 2001 to 2008Preliminary results from a meta analysis of FSNAU surveillance data 2001 to 2008 reveal that median rates of global acute malnutrition for this period did not vary significantly, remaining at Critical levels (WHO Classification 2000) throughout, with a national median rate of 15.7%. National median rates of stunting for the same period were 23.2%, ie at serious levels according to WHO classification 2000. Rates range from 12.4% in Togdheer region to 37% in Bay region. These results highlight how unacceptably high rates of acute and chronic malnutrition are a persistent problem in Somalia.
Differences in malnutrition among the livelihood zonesFigure 6 shows variation in median malnutrition rates for the period 2001 to 2008 according to type and by livelihood group. Rates of GAM differentiated by livelihood group were not significantly different from the national median rate. However, riverine and agropastoralist groups had the highest median rate of wasting, stunting and underweight suggesting a higher nutritional vulnerability to shocks of flooding drought, displacement and disease outbreak. Pastoralist group had the lowest rates of stunting. This may be due to physical stature masking the actual estimate (Sadler et al 2009).
Differences in malnutrition – Somaliland, Puntland and South Central Somalia Figure 2 highlights how median rates of wasting, stunting and underweight for the period 2001-2008 are all higher in South Central Somalia than Puntland and Somaliland. This reflects the chronic humanitarian situation in the zone where conflict and violence prevail with additional recurrent shocks of drought and flooding causing loss of livelihoods. Somaliland has experienced relative tranquillity and this is reflected in lower rates of malnutrition.
The meta analysis of FSNAU data from 2001 to 2008 also demonstrates how in all but one year (2003), median GAM rates in South Central Somalia exceeded the emergency threshold of 15%. In 2003, the median GAM rate for South Central Somalia was still high at 13.3%.
17.25 15.7
17.9 17.1
12.1
20.6
31.5
19.3
29.7
38.2
14.4
24.6 24.9
19
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IDP
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Median Wasting Median stunting Median Underweight
Figure 6: Trends in different types of malnutrition in Somalia by livelihood group
Source: FSNAU 2010
45 The results of the National Micronutrient and Anthropometric Nutrition survey 2009 confirm this pattern of higher prevalence of stunting and wasting in South Central Somalia compared to Somaliland and Puntland (see figure 7). The meta analysis of data for 2010-2008 also reveals variation by region. Gedo region is the worst affected region across the country with a median acute malnutrition rate of 21.5% and a persistently Very Critical nutrition situation. Galgadud (18.4%), Bay (18.0%), Bakool (17.1%) and Hiran (16.7%) also show high median wasting rates over the period 2001-2008.
2.4 Micronutrient malnutritionThroughout Somalia the presence of risk factors for micronutrient malnutrition (poverty, poor access to food, low diet diversity, high morbidity) is high suggesting micronutrient deficiencies are a significant public health problem. The findings of MICS 2006 showed that only 1.2% of households use iodised salt while coverage of Vitamin A supplementation in children 6 to 59 months was 24% but otherwise data on the extent of the problem was limited. In 2009 a national micronutrient and anthropometric nutrition survey was conducted to address the information gap and inform appropriate responses. The national two stage cluster survey was conducted in the three zones to determine the prevalence of vitamin A deficiency, Iron deficiency and anaemia in children 6-59 months and women of reproductive age and iodine deficiency in school aged children and women. Information was also collected regarding infant feeding and care practices and anthropometric status. Field work was completed between March and August 2009, followed by laboratory analysis of samples.
Results of the survey demonstrated the prevalence of both nutritional anaemia and vitamin A deficiency in women and children of all age groups are severe according to WHO classifications and therefore are of significant public health importance.
Anaemia prevalence was 59.3% for children aged 6 to 59 months, 38.5% for school aged children, 46.6% for non pregnant women and 49.1% for pregnant women. In children aged 6 to 59 months, there was no significant difference in prevalence of anaemia between the zones but rural children were found to be 50% more at risk of developing anaemia than their urban counterparts. There was also a significant difference between prevalence of anaemia in children less than two years (73.7%) and those over two (51.9%).
Findings for the prevalence of vitamin A deficiency indicate a severe situation according to the WHO classification of above 20% prevalence, across all zones and each group. Among children 6 to 59 months, the overall prevalence of vitamin A deficiency was 33.3%, with a higher prevalence in South Central Somalia (40.7%) compared to Somaliland (25.6%) and Puntland (24.1%). Similarly, overall prevalence of vitamin A deficiency in school aged children was 31.9% and in women, 54.4%.
1.3
10.7
16.5
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Source: FSNAU 2010
Figure 7: Malnutrition rates by zone, according to National Anthropometric Micronutrient Survey results 2009
Testing for Anaemia, FSNAU
46 Regarding iodine, interestingly, the survey found high urinary iodine concentrations in all groups. The reasons for this are not clear at this stage and will be subject to further investigation. Possible reasons include dehydration of subjects or high iodine content of water but do not include high intakes of iodised salt as overall use of iodised salt was found to be very low at 3.9% (0.4% in the Somaliland, 0.15 in Puntland and 6.7% in South Central Somalia. The prevalence of visible goitre among women was significant in Somaliland at 3.3% compared to 1.4% in South Central Somalia. This indicator was not investigated in Puntland. Goitre can be due to excessive or inadequate intake of iodine.
3. Determinants of Malnutrition in Somalia Malnutrition results from a complex set of factors and not one simple cause. The UNICEF conceptual model of the causes of malnutrition (see figure 8 below) provides a useful framework for the discussion of determinants of malnutrition in Somalia. The volatile political situation and its resulting insecurity, civil unrest or outright war have led to a chronic and continuing humanitarian crisis that is at the root of the high prevalence of malnutrition in Somalia. However, even in years of relative stability and improved food production, the malnutrition rates in some regions of Somalia have remained consistently high, providing evidence for the contribution of underlying causes.
3.1 Food security (Food access and availability)Somalia is chronically food insecure. Overall, around 80% of Somali households rely on natural resource-dependent activities for their livelihood, making them highly vulnerable to environmental factors and shocks. Even in good years, Somalia is only able to produce 40% of its cereal requirements. In the last five years, local production has averaged about 30% of food needs. (ref WFP website). Somalia was a major recipient of international food aid even before the collapse of central government in 1991.
Food security varies wildly by area, season and according to climatic, political and economic factors (openness of cross border markets and internal urban markets). Traditionally, the sedentary farmers of the Juba valley and around Baidoa have suffered the most acute and long lasting nutritional crisis. In comparison the pastoralists have fared best as their mobile, cattle based strategy is flexible and adaptive to the stresses of conflict and insecurity. Pastoralists rely on the consumption and sale of milk and animal products for their livelihoods. Livestock milk availability and consumption has a very significant influence over the nutritional status of the pastoralist population as shown by a case study from West Golis/Guban livelihood zone described in the FSNAU Post Gu 2009 assessment. This shows that once availability of milk declines eg due to loss of livestock resulting from disease outbreak and or drought conditions, rates of acute malnutrition deteriorate to very critical levels but improve again once the livestock situation recovers and availability of milk increases. As discussed in the case study this demonstrates the natural ability to recover from shocks provided that they are not recurrent and cumulative.
According to FEWS Net, underlying causes of food insecurity in the country are the following:•Successive seasons of poor rains and seasonal flood affected crop and livestock production,
which are the two main livelihood sources for the majority of the rural population.•Recurrent conflict and civil insecurity, which have resulted in civilian displacement and
restriction of internal and cross border trade flow.•Chronic macroeconomic shocks, such as the persistent ban of livestock export and lack of
employment opportunities, affected investment in productive sectors like crop and livestock.
Results of the most recently conducted FSNAU led multi-agency post deyr ‘09/10 seasonal assessment indicate some improvement in the overall food security situation in country, especially in rural areas of the south where crop and livestock production has improved following normal deyr rains. However, although the number of people estimated to be in need of emergency
47 humanitarian assistance and livelihood support has dropped to about 3.2 million (42% of the total population), this situation still represents a widespread Humanitarian Crisis affecting 42% of the total population. Conditions in the central regions of Mudug, Hiran and Galgadud are of particular concern. Failure of the deyr rains combined with escalation of conflict and resulting population displacements, on top of six consecutive seasons of drought mean that here 70% of the population are in need of urgent humanitarian assistance, which in turn is more difficult to deliver in the context of heightened insecurity and reduced access. The deyr rains also performed poorly in pastoral regions of the north and north east and has resulted in a deepening crisis in the Hawd, Addun and Sool plateau pastoral livelihood zones, with complete loss of livestock assets, especially sheep and goats.
Figure 8: UNICEF Conceptual model of causes of malnutrition (taken from Lancet series on maternal and child undernutrition 2008
12 | The neglected crisis of undernutrition: DFID’s strategy CHAPTER 3The determinants
Figure 3: Framework of the causes of maternal and child undernutrition and its short term consequences
Short term consequences:
Mortality, morbidity, disability
Household food insecurity
Income poverty: employment, self-
employment, dwelling, assets, remittances,
pensions, transfers etc
Social, economic and political context
Lack of capital: financial, human, physical, social
and natural
Inadequate careUnhealthy household environment and lack
of health service
Long term consequences:
Adult size, intellectual ability, economic productivity, reproductive
performance, metabolic and cardiovascular disease
Inadequate dietary intake Disease
Underlying causes
Basic causes
Immediatecauses
Maternal child undernutrition
Source: Lancet Series on Maternal and Child Undernutrition, 2008.
48 At household level, indicators of food security include number of meals eaten per household per day and diet diversity or number of different food groups consumed a day. Results from the micronutrient study 2009 indicate that food security as measured by number of meals eaten per day is poorer in South Central Somalia where the majority of households (73.7%) consume two meals a day compared to Somaliland where the majority (64.8%) consume three meal a day. In Puntland, 45.2% households reported consuming two meals a day while 41.4% consume three meals a day.
Diversity of the diet at household level also reflects the adequacy of food access and availability. Dietary diversity is generally poor in Somalia and also relates to poor knowledge and food habits. Diets consist mainly of cereal (maize or rice) oil, sugar, seasonably variable access to milk and occasional access to meat. Vegetables and/or fruit are rarely consumed. Patterns differ for pastoralist populations for whom milk makes more significant contribution to the diet. According to the micronutrient study 2009, the percentage of households consuming less than four foods a day was similar across all three zones - between 15 and 20% for South Central Somalia and Somaliland and less than 10% for Puntland; the difference was not significant. The mean number of food groups consumed per day was 5.52. Results from WFP seven day recall assessment in Somaliland (WFP Food Security and Vulnerability Assessment 2008), highlight there is large variation by region and livelihood zone. Overall, 28% of the population consumed less than four food groups in the seven days prior to the survey but in some areas, up to 45% population consumed less than four food groups. 20% of the population were only consuming a staple, oil and sugar. 68% had seasonably variable access to milk and occasionally meat. In Puntland 2007, only 2% of households had a diet that included fruit. Results from the National Micronutrient and Anthropometric Nutrition survey 2009 also show that consumption of micronutrient rich foods including fresh fruits, vitamin A rich vegetables fish, eggs and meat products was generally poor across all three zones.
According to the FSNAU Post Gu 2009 assessment, dietary diversity is particularly poor in Bay and Bakool regions, where surveys found that 49% of Bay agro pastoralists, 55% of Bakool agro pastoralists and 61% of Bakool pastoralist households ate less than 4 food groups in the previous 24 hours. According to the same seasonal assessment, Bay and Bakool regions have the highest rate of chronic malnutrition. The other significant group found to have poor dietary diversity was IDPs in the northwest; 37% of households consumed less than four food groups a day. Poor dietary diversity was identified as a main factor contributing to the Very Critical nutrition situation of this IDP group in the post Gu ‘09 assessment. Generally, urban households are found to have greater household dietary diversity, according to FSNAU data. Preliminary results from the FSNAU meta analysis 2001-2008 highlight the link between diet diversity and nutritional status, finding that children who consumed a less diverse diet (three or fewer food groups) were 1.12 times more likely (p=0.001) to be malnourished than those who consumed more diversified food groups.
Manoocher Deghati IRIN
49 3.2 Social and care environmentThis refers to the ‘wider social and cultural context that shapes caring behaviours within the household and local community’ (Young & Jaspers 2006). Appropriate child care including sound feeding practices, good hygiene, emotional support and appropriate health related behaviours are all essential for good nutrition and health.
The FSNAU KAP survey of 2007 revealed the extent of poor care practices for children and mothers. The study identified the following as significant problems:Poor breast feeding practicesEarly introduction of feeds Birth spacing less than 1.5 yearsInadequate care for women/mothers Poor complementary diets – in particular among riverine and agro pastoralistsPoor hygiene practicesInappropriate home health practices during illnessDelay in seeking appropriate medical care
According to KAPS 2007 findings, throughout Somalia, initiation of breastfeeding is delayed till 2-3 days postpartum, as colostrum, is deemed harmful. However, results of the National Micronutrient and Anthropometric Nutrition survey 2009 shown in figure 9 taken from the survey report, indicate this practice is not as widespread as KAPS 2007 suggests. Overall, around 50% mothers reported initiation of breastfeeding within 3 hours of delivery.
However, while breastfeeding is initiated by most women and practiced well into the 1st month postpartum, breastfeeding is not exclusive. Children are given water with sugar or other liquids such as cow or goat milk. According to a study of breastfeeding and dietary habits of children in rural Somalia (Ibrahim et al 1991), there was a complete absence of exclusive breastfeeding. Median duration of breastfeeding was 19.5 months but all children also received cow’s milk by cup from the first day of life. Sugar, oil and water were also given daily from early infancy. The findings of MICS 2006, indicate that only 9% of infants are exclusively breastfed for 6 months. More recently, the national micronutrient and anthropometric nutrition survey 2009 found rates of exclusive breastfeeding to be 5.3% (95% CI 3.1 – 9.2%), with most mothers giving additional water. With the poor availability of safe water and the poor development of the child immune system, the likelihood of introducing water borne infections is high. Rates of exclusive breastfeeding were lowest in South Central Somalia, only 2.8% (95% CI 0.9 – 8.2%) and highest in Somaliland 12.7% (95% CI 6.7 – 22.7%); the rate in Puntland was 6.3% (95% CI 1.6 – 21.6%). According to the national micronutrient and anthropometric nutrition survey 2009, 60.8% of children aged 12-16 months were still being breastfed. This fell to 26.8% in the 20-23 month age group. Reasons for low levels of breastfeeding in Somalia include lack of knowledge of the importance of the practice, vigorous advertising of infant formulas and the persistence of inaccurate information and myths around breastfeeding. The reasons for apparent better breast feeding practices in Somaliland are worth further investigation and may provide lessons learned to be applied in Puntland and South Central Somalia.
Figure 9: Breast feeding initiation
(Source National Micronutrient and Anthropometric Nutrition Survey 2009)
Furthermore, adequate complementary feeding, defined by frequency and suitability of foods given, among all infants 0 to 11 months was just 11% with little variation according to mother’s education, wealth, or urban-rural residence (MICS 2006), i.e. only one in ten are considered appropriately fed. By 24 months, children are expected to fend for themselves and eat like adults. As highlighted in the previous section, diversity of children’s diets is poor and nutrient density low.
The KAPS study also identified widespread inappropriate home health practices during illness. One indicator of this is the change in frequency with which foods (breastfeeding and/or other foods) are offered during diarrhoea compared to when the child is healthy. According to results of the micronutrient survey, combined data for the three zones showed that 36.2%, 51.5% and 9.6% were offered feeding less that normal, same as normal and more that normal respectively during episodes of diarrhoea. 9.6% and 2.7% of the combined strata were given reduced feeding or withdrawn from feeding completely. Reduced feeding as well as withdrawal during diarrhoea can reduce the chances of full recovery and is an important risk factor for developing severe malnutrition. Practices were found to be particularly poor in Puntland, where no children were given more food, whilst around 70% were given less food than normal and for around 8% food was withdrawn completely during diarrhoea.
Often the care of children is closely linked with cultural and gender issues. In Somali society, women have a progressively stronger role to play in raising children, managing the household and earning income. However, male heads of household continue to make the main decisions over use of time and resources. Generally there is low value placed on women’s health and although they may exercise greater power over health seeking behaviour for their children, they lack decision-making power over their own health. In general, women have far lower levels of education and lower access and utilisation of health services with rural women the most disadvantaged. Furthermore, as figure 10 taken from MICS 2006 below shows, a significant number of pregnancies occur in the 15 to 19 years age group, particularly for rural women. All these factors adversely affect the social and care environment of women and children and therefore their survival and nutritional status.
Maternal mortality ratio (MMR) is estimated as 1044 per 100,000 live births (MICS 2006) which is one of the highest in the region and corresponds to a lifetime risk of 1 maternal death for every 10 women. The high MMR is related to many factors including low age at first birth, high fertility rate, low skilled attendance at birth, poor maternal nutritional status and the presence of female genital mutilation. Limited basic care facilities – referral hospitals, MCH services, almost complete lack of emergency obstetric referral care for complications. According to MICS 2006, around a quarter of pregnant women have one antenatal care consultation. Only 6% of pregnant women visit the antenatal clinic more than 4 times. During delivery, 1 in 3 women are attended by a skilled attendant (doctor nurse, midwife or auxiliary midwife) but less than 10 % delivers in a health facility. Of women who had given birth in the preceding 2 years, 88% had received no postnatal care (MICS 2006). Data on low birth weight is very limited as only 5% of infants in Somalia are weighed at birth. According to MICS 2006, of those weighed at birth, 5% weighed less than 2500g.
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Figure 10: Age-specific fertility rates by urban-rural residence, Somalia 2006
(source: MICS 2006 report)
51 3.3 Access to health services and healthy environment Public health programmes are critical in the prevention and control of disease and therefore in protecting and supporting nutrition. After eighteen years of conflict, the health care system in Somalia remains underdeveloped, poorly resourced, inequitable and unbalanced. The public health care delivery system operates in a fragmented manner, maintained largely by medical supplies provided by UNICEF and other agencies. In the absence of an efficient and adequate public health system, the private sector has flourished but remains unregulated with poor quality of services and poor access to the rural population. Over half of the estimated health workforce is unskilled and unsupervised and staff are paid a below subsistence wage. Most public facilities operate at a level far below their intended capacity and are poorly organized, with very low utilization rates (estimated as on average, one contact every eight years, according to Rossi and Davies 2008).
According to KAP study 2007, most health seeking responses are based on the traditional knowledge, beliefs and the perceived causes of the specific illnesses. Traditional healing and the use of herbal medicine play a major role in the management of illnesses for most communities. Across all livelihood zones, the first step in health seeking response for most caregivers is prayer or reading the Koran, after which most people buy drugs. Visiting a health facility only comes after all else has failed. There is a general lack of confidence towards public institutions.
Not surprisingly, overall coverage of essential health services is low, especially for rural and nomadic populations. According to MICS 2006, immunization coverage (1 year olds fully immunized) was only 5%, while 12% of children aged 12 to 23 months had received all three doses of DPT, for measles 29%. Of mothers who gave birth in the previous two years before the MICS 2006, only 9 percent received a Vitamin A supplement within eight weeks of the birth. Within the six months prior to the MICS, 24 percent of children aged 6-59 months had received a high dose Vitamin A supplement. More recent data from the national micronutrient and anthropometric nutrition survey 2009 results are summarised in figure 11 and suggest improved coverage of both immunisation and vitamin A. Overall coverage of vitamin A was 44.6% for children under five years of age. Coverage for Somaliland and South Central Somalia was significantly higher but this was related to recent implementation of Child Health Days in the two zones prior to the survey being conducted.
A healthy environment in terms of adequate supplies of clean water, sufficient sanitation, appropriate shelter and clothing are crucial in terms of reducing exposure to disease. Throughout Somalia, the water and sanitation situation is extremely poor. MICS 2006 found that only 29% of the population had access to an improved source of drinking water (58% in urban areas, 14% in rural areas, 4% in nomadic groups). 81% of the rural population practices open defecation. More recently, the national micronutrient and anthropometric nutrition survey 2009 reported the use of improved water source in Somalia overall to be 32%. This suggests some improvement in access to safe water may have taken place over the four years between surveys.
Figure 11: Immunisation coverage among children under five years
Source Micronutrient Survey 2009
Only just over half of households (55%) report that soap in the household was used for washing hands in one or more of the given situations (MICS 2006). The lack of clean water, poor hygiene and environmental sanitation are major causes of diseases in particular diarrhoeal diseases and cholera. Diarrhoeal diseases are the cause of 19% of deaths of children under five. According to MICS 2006, only 7% of children with diarrhoea receive appropriate treatment (ORS and continued feeding). Preliminary results from the FSNAU meta-analysis 2001-2008 indicate that diarrhoea is a significant predictor of acute malnutrition. The paradox is that the water and sanitation situation are major underlying cause of morbidity and malnutrition in Somalia, yet interventions have been relatively poorly funded.
The relationship between malnutrition and morbidity is well established. Disease outbreaks have shown to have a significant effect on malnutrition rates in Somalia. In Lower and Middle Juba regions, since March 2009 an outbreak of acute watery diarrhoea across all livelihoods coincided with a significant deterioration in the nutrition situation to Very Critical despite improvements seen in food security indicators in the region. In Shabelle and Juba, high rates of malnutrition were attributed to high incidence of acute watery diarrhoea and acute respiratory tract infections (FSNAU Post Gu 2009 assessment).
3.4 EducationThe UNICEF conceptual model highlights inadequate education as one of the basic causes of malnutrition. According to UNICEF, only 24% of women are literate, while 20% of girls attend school. Overall 23% of children (25% of boys and 21% of girls) of primary school age attend primary school, (44% urban, 12% rural). For every 10 boys attending primary school, there are 8 girls, while for secondary school, for every 10 boys attending, only 5 girls. A large number of secondary school age children attend primary school due to lack of schooling opportunities that followed the overthrow of Siad Biarre in 1991 and the social chaos.
While each of these groups of underlying causes has been discussed independently of each other, there is a clear inter-connectedness between them. Underlying causes are overlapping and have a synergistic effect so that the combined effects of a failure of all three causes are much greater than the sum of their parts. This is the foundation of the need for an integrated, multi sectoral response. As discussed, different causes differ in their significance for the different regions and livelihoods. For example in urban populations, dietary diversity is much better than for the rural populations, and sub optimal care practices such as use of breast milk substitutes may be more significant in the explanation of malnutrition.
4. Current Nutrition Interventions In response to persistently high rates of acute malnutrition, current nutrition interventions have been focused on saving lives through the management of acute nutrition. 4.1 Nutrition Cluster Due to weak governance structures in parts of Somalia, nutrition response programming is mainly undertaken by UN, international and national agencies. The Nutrition Working Group (NWG) was initiated in 1995 to coordinate nutrition related issues. In 2006, as part of the UN Humanitarian Reform, the cluster approach was introduced. From the start this was integrated into the existing NWG. Thus the Nutrition Cluster and NWG exist as a single coordination structure, referred to as the Nutrition Cluster, for nutrition activities in Somalia. The primary purpose of the Nutrition Cluster is “to support and strengthen a coordinated approach in nutrition strategic planning, situation analysis and response both in emergencies and non-emergency situations.” (Nutrition Cluster TORs Dec 2009). There are currently 79 members of the Nutrition Cluster including local and international NGOS and UN agencies working in the field of nutrition in Somalia.
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53 4.2 Food Security and Nutrition SurveillanceThe Food Security and Nutrition Analysis Unit (FSNAU) is managed by FAO and funded by USAID/OFDA, the EC, SIDA, UNICEF and UNHCR. It has developed a very sophisticated system of regular and exhaustive food security and nutrition assessments. Information is collected through different surveillance systems including nutrition surveys, rapid Mid Upper Arm Circumference (MUAC) assessments, passive health facility-based screening and at some times and places, sentinel site surveillance. Data is analysed in the context of morbidity and food security indicators. Bi monthly nutrition updates are produced and bi annual assessments of the food security and nutrition situation are published. The food security and nutrition surveillance data is an important tool providing regular situational analysis to inform and guide appropriate responses to expected caseloads of acutely malnourished and emerging needs.
Additional food security information is provided through the Famine Early Warning Systems Network (FEWS NET). This is a USAID-funded activity that collaborates with international, regional and national partners to provide timely and rigorous early warning and vulnerability information on emerging and evolving food security issues. FEWSNET produces monthly food security updates, regular food security outlooks and alerts, as well as briefings and support to contingency and response planning efforts. More in-depth studies in areas such as livelihoods and markets provide additional information to support analysis as well as program and policy development.
WFP undertakes regular monitoring of market prices and has conducted baseline livelihood studies. Food security and vulnerability assessments have been conducted and published for Puntland in April 2007 and Somaliland in August 2008. Smaller assessments have completed in Mogadishu, Bossaso, El Wak in the South. A food security and vulnerability assessment is planned for Central region in 2010.
4.3 Management of severe acute malnutritionOutpatient therapeutic feeding programmes (OTPs) for the treatment of severe acute malnutrition are being implemented across Somalia by international NGOs and UNICEF in partnership with local NGOs, according to the “Operational Guidelines for the Treatment of Acute Malnutrition in Somalia” which were developed by the nutrition cluster in 2005, taking into account the challenging environment, reduced supervision and limited monitoring. Complicated cases are referred to stabilisation centres (SCs) for the initial period of treatment, although distance and location of centres in opposing clan territories are often barriers to access. WFP provides a caregiver and discharge rations in selected centres across Somalia. In 2009, UNICEF aimed to reach 60% of children under five with severe acute malnutrition through technical support and training of NGO partners and distribution of feeding supplies. At the time of writing there are 250 outpatient units for the ambulatory treatment of severe acute malnutrition in Somalia and around 20 in patient stabilisation centres, all but four integrated into existing health structures. This scale up of services for the management of acute malnutrition is impressive but gaps remain in the geographical coverage of OTPs and SCs due to the insecure environment, fragmented health system and availability of capable local partners. Map 1 on page 7 shows a map of the current nutrition situation and interventions as of November 2010.
Measuring MUAC, IDP camp, Jowhar, UNICEF Somalia, Nick Ysenburg
54 4.4 Management of moderate acute malnutritionTargeted supplementary feeding programmes (SFPs) for the treatment of moderately malnourished under-fives and pregnant and lactating women are being implemented by WFP through around 40 local and international NGOs. The current caseload is around 70,000 beneficiaries, of whom approximately 80% are under-fives and 20% pregnant and lactating women. 50,000 beneficiaries are being treated with corn soya blend (CSB), fortified vegetable oil, and sugar. In a pilot intervention, 20,000 are to receive ready-to-use supplementary food (supplementary plumpy) in Bakool, Bay, and Benadir regions of South Central Somalia, and in Puntland and Somaliland. In addition, WFP is providing a ‘protection’ ration for families of moderately malnourished under -fives. This currently provides around 60% of the energy needs of the family.
4.5 Prevention of moderate acute malnutrition – food based interventionsIn selected sites in Puntland and Somaliland, WFP is providing fortified supplementary food to all children under-two and pregnant and lactating women through UNICEF supported MCH clinics. Currently 35 clinics are supported.
As a new initiative, during 2009 UNICEF launched a pilot intervention for the prevention of malnutrition targeting 100,000 children aged 6-36 months blanket distribution of ready-to-use food (Plumpy Doz) every two months in areas showing the highest malnutrition rates, with a particular focus on the Central and South Somalia, in Middle and Lower Shabelle and IDP camps in the north and poor urban areas.
From May to August 2009, WFP launched and completed an emergency blanket supplementary feeding covering 135,000 children aged 6-59 months in Galgadud and Mudug regions of Central Somalia as well as South Nugal in Puntland. This intervention was designed to prevent and treat moderate malnutrition in areas where very critical rates of malnutrition were recorded (GAM>20%) with very limited access to nutrition services.
4.6 Institutional Feeding & School FeedingWFP is providing nutritional support to other vulnerable groups including HIV positive and TB cases, orphans, the mentally handicapped, and hospitalized patients either as a take home ration or as daily meals for in patients. This intervention currently supports 60,000 people including the family protection ration.
Around 90,000 school children provided with meals at school from fortified foods. Girls receive a take home ration of fortified oil to encourage attendance.
4.7 General food distributionWFP is providing food assistance to the rural population affected by the humanitarian crisis, the urban poor and IDPs with general food ration consisting of cereals, CSB, sugar, fortified oil and iodised salt when available. In 2009 WFP reached 3.3 million people a month on the basis of FSNAU seasonal assessments.
School feeding, WFP Khalif
55 4.8 Nutrition activities delivered through the health sectorNutrition interventions are delivered through the 3 levels of the health system – health posts, MCH Clinics and hospitals. Coverage and quality is currently limited due to overall weaknesses of the public health system.
A key intervention of the UNICEF/WHO Accelerated Young Child Survival initiative is the bi annual Child Health Days. These population based campaign days aim to provide at least 80 per cent of under-fives and over 60 per cent of women of child bearing age nationwide with high-impact child survival interventions: immunization against measles, polio, vitamin A supplementation, deworming, provision of oral rehydration salts, water treatment tablets, hygiene education, nutritional screening, and tetanus toxoid vaccination for women. These campaign days are especially important in the context of the majority nomadic and rural population who have limited access to regular health services.
4.9 Other sector activities with nutrition focus- FAO Trials of Improved Practices. This project aims to identify and implement the most acceptable practices in the region for improving infant and child feeding practices. The method involves discussion with the mothers and caregivers in moving towards recommended IYCF over three household visits. The aim is to move from ideal recommendations to practical realistic recommendations. The project has been piloted in Hiran and Gedo regions which were identified by KAPs 2007 as being particularly vulnerable in IYCF.
- EU and FAO Integrated Support to Rural Livelihoods. The aim of this project is to mitigate the effects of soaring food prices in 2009 for 78,100 households in South Central Somalia. It aims to enhance agricultural production through cash for work programmes, distribution of packaged seed kits, tools and fertilizers. Resulting improvements to livelihood and food security should have a positive impact on nutritional status.
4.10 Strengths, weaknesses, opportunities and threats of current interventionsTable 1 summarises a SWOT analysis of the current nutrition interventions in Somalia. This analysis highlights the strengths of nutrition and food security surveillance and the current interventions for the management of acute malnutrition; weakness in areas of interventions to address underlying causes of malnutrition; opportunities for integration of complementary activities into existing nutrition programmes and the significant threats to quality programming by insecurity and poor access, weak health systems and low human resource capacity. In such a challenging operating environment, the use of existing programmes and structures as a delivery mechanism for integrated activities is crucial.
Table 2 summarises key existing initiatives and the opportunities they offer as delivery mechanisms for strengthening nutrition interventions.
56
Op
po
rtu
nit
ies
1.
Inte
grat
ion
of n
utrit
ion
activ
ities
into
exi
stin
g pr
ogra
mm
es –
(see
tabl
e 2)
2.
Inte
grat
ion
of I
YC
F, h
ygie
ne p
rom
otio
n, d
eliv
ery
of b
asic
hea
lth s
ervi
ces
into
exi
stin
g nu
tritio
n pr
ogra
mm
es (O
TP/S
FP s
ites)
3.
Pro
ven
effe
ctiv
e in
terv
entio
ns th
at a
re c
ost e
ffect
ive
are
avai
labl
e (L
ance
t se
ries,
Cop
enha
gen
cons
ensu
s) o
f w
hich
are
fea
sibl
e to
Som
alia
in t
he
next
thre
e ye
ars
4.
Exi
stin
g in
tern
atio
nal g
uide
lines
and
reso
urce
s th
at c
an b
e ad
apte
d to
the
Som
ali c
onte
xt
5.
Pilo
t of
new
ini
tiativ
es b
y sp
ecifi
c ag
enci
es –
FA
O T
IPS
, C
omm
unity
C
onve
rsat
ions
by
Con
cern
Wor
ldw
ide
6.
In g
ood
year
60%
cer
eals
are
im
porte
d, c
reat
ing
oppo
rtuni
ty f
or c
erea
l fo
rtific
atio
n at
sou
rce
7.
Dev
elop
men
t of i
mpr
oved
CS
B b
y W
FP H
Q
8.
Dev
elop
men
t of
oth
er p
rodu
cts
for
mic
ronu
trien
t su
pple
men
tatio
n eg
sp
rinkl
es, n
utrib
utte
r whi
ch fo
cus
on fo
rtific
atio
n at
poi
nt o
f use
9.
Mic
ronu
trien
t su
pple
men
tatio
n ha
s hi
gh c
ost
bene
fit r
atio
. C
open
hage
n co
nsen
sus
10.
Exi
stin
g pr
e-se
rvic
e tra
inin
g in
stitu
tions
– o
ppor
tuni
ties
for
deve
lopi
ng
nutri
tion
curr
icul
um
– do
ctor
s,
nurs
es,
nutri
tion
cour
ses.
Li
nks
to
inte
rnat
iona
l ins
titut
ions
11.
Inte
rnet
acc
ess
in S
omal
ia f
or li
nks
to w
ell r
ecog
nise
d di
stan
ce le
arni
ng
cour
ses
for c
apac
ity d
evel
opm
ent
Th
reat
s1.
P
rolo
nged
abs
ence
of u
nifie
d ce
ntra
l gov
ernm
ent l
imiti
ng o
ptio
ns fo
r nat
iona
l pol
icy
fram
ewor
k an
d gu
idel
ines
2.
Inse
curit
y an
d co
nflic
t re
duci
ng a
cces
s to
sup
ervi
se a
nd e
xpan
d pr
ogra
mm
es,
train
sta
ff,
deve
lop
outre
ach
activ
ities
3.
Loot
ing
of s
uppl
ies
disr
uptin
g pi
pelin
e an
d di
strib
utio
n
4.
Glo
bal e
cono
mic
situ
atio
n an
d po
litic
al is
sues
affe
ctin
g fu
ndin
g of
pro
gram
mes
5.
Sho
rt te
rm fu
ndin
g fo
cuse
d on
em
erge
ncy
inte
rven
tions
rat
her
than
med
ium
to lo
nger
term
in
itiat
ives
6.
R
ecur
rent
dro
ught
s an
d flo
ods,
7.
A
ctiv
e pr
omot
ion
and
adve
rtisi
ng o
f br
east
milk
sub
stitu
tes.
Eco
nom
ic in
tere
sts
of t
rade
rs/
impo
rters
8.
Trad
ition
al,
gene
ralis
ed p
oor
feed
ing,
hyg
iene
, sa
nita
tion
and
mat
erna
l an
d ch
ildre
n ca
re
prac
tices
9.
Dis
pers
ed n
atur
e of
mal
nour
ishe
d po
pula
tion
over
wid
e ge
ogra
phic
al a
rea
10.
Diffi
culti
es o
f pro
vidi
ng h
ealth
and
nut
ritio
n se
rvic
es to
a s
ubst
antia
l nom
adic
pop
ulat
ion
and
in
arid
low
pop
ulat
ion
dens
ity a
reas
11.
Wat
er a
nd s
anita
tion
situ
atio
n12
. W
omen
’s p
ositi
on in
Som
ali s
ocie
ty e
spec
ially
in r
ural
are
as -
low
er le
vels
of e
duca
tion
and
low
er a
cces
s an
d ut
ilisa
tion
of h
ealth
ser
vice
s 13
. H
uman
reso
urce
s fo
r nut
ritio
n –
educ
atio
nal l
evel
gen
eral
ly v
ery
poor
, nut
ritio
n tra
inin
g in
pre
se
rvic
e in
stitu
tions
lim
ited,
Wea
knes
ses
1.
Geo
grap
hic
gaps
in c
over
age
of m
anag
emen
t of a
cute
mal
nutri
tion
2.
Li
mite
d st
abili
satio
n ce
ntre
s fo
r co
mpl
icat
ed s
ever
e ac
ute
mal
nutri
tion
– di
stan
ce,
trans
port,
cro
ssin
g cl
an a
reas
3.
Low
rep
ortin
g of
fee
ding
pro
gram
me
perfo
rman
ce in
dica
tors
– on
ly 6
0% f
rom
UN
ICE
F im
plem
entin
g pa
rtner
s4.
M
appi
ng o
f cur
rent
nut
ritio
n in
terv
entio
ns is
unr
ealis
tic -
age
ncie
s ha
ve s
topp
ed b
ut n
ot
refle
cted
on
inte
rven
tions
map
5.
La
ck o
f int
egra
tion
of e
ssen
tial c
ompl
emen
tary
act
iviti
es in
to e
xist
ing
nutri
tion
prog
ram
mes
eg
dew
orm
ing,
IY
CF,
nut
ritio
n an
d hy
gien
e ed
ucat
ion
to g
ive
com
plet
e pa
ckag
e of
se
rvic
es,
6.
Poo
r qu
ality
& c
over
age
of n
utrit
ion
inte
rven
tions
del
iver
ed t
hrou
gh h
ealth
fac
ilitie
s –
nutri
tion
coun
selli
ng, m
icro
nutri
ent s
uppl
emen
tatio
n, d
ewor
min
g7.
Li
mite
d IY
CF
inte
rven
tions
8.
Mic
ronu
trien
t int
erve
ntio
ns li
mite
d to
CH
Ds,
forti
fied
ratio
ns &
SFP
s 9.
E
ffica
cy o
f ble
nded
food
(C
SB
) fo
r m
anag
emen
t of m
oder
ate
mal
nutri
tion
is lo
w d
ue to
hi
gh p
hyta
te c
onte
nt a
nd p
ract
ical
diffi
culti
es to
pre
mix
ble
nded
food
with
oil
and
suga
r. W
eak
supe
rvis
ion
also
redu
ces
succ
ess
10.
Doc
umen
tatio
n of
exp
erie
nces
of w
hat w
orks
in S
omal
i con
text
11.
Con
stra
ints
on
mon
itorin
g an
d ev
alua
tion
due
to a
cces
sibi
lity
issu
es
Str
eng
ths
1.
Out
patie
nt m
anag
emen
t of
sev
ere
acut
e m
alnu
tritio
n us
ing
adap
ted
inte
rnat
iona
l pro
toco
ls to
the
situ
atio
n in
Som
alia
– fl
exib
le a
ppro
ach
2.
The
qual
ity o
f foo
d se
curit
y an
d nu
tritio
n su
rvei
llanc
e in
form
ing
appr
opria
te
resp
onse
s3.
N
utrit
ion
clus
ter c
o-or
dina
tion
– m
embe
r par
ticip
atio
n co
oper
atio
n4.
Tr
ials
of
new
app
roac
hes
to m
anag
emen
t of
mod
erat
e m
alnu
tritio
n –
Sup
plem
enta
ry P
lum
py a
nd p
reve
ntio
n of
mal
nutri
tion
- Plu
mpy
Doz
5.
D
edic
ated
par
tner
s w
ho h
ave
scal
ed u
p se
lect
ive
feed
ing
inte
rven
tions
de
spite
ong
oing
inse
curit
y
Tabl
e 1:
SW
OT
Ana
lysi
s of
cur
rent
nut
ritio
n in
terv
entio
ns in
Som
alia
57
Prog
ram
me
& o
verr
idin
g ob
ject
ives
Key
nut
ritio
n re
late
d pr
ogra
mm
e ob
ject
ives
Key
pro
gram
me
activ
ities
Opp
ortu
nitie
s fo
r int
egra
tion
of n
utrit
ion
activ
ities
Uni
ted
Nat
ions
Tra
nsiti
on P
lan
for
Som
alia
200
8-09
Thre
e co
re ‘p
illars
’ or o
vera
ll go
als:
i)
Dee
peni
ng p
eace
, im
prov
ing
secu
rity
and
esta
blis
hing
goo
d go
vern
ance
; (ii
) Inv
estin
g in
peo
ple
thro
ugh
impr
oved
so
cial
ser
vice
s; a
nd
(iii)
Cre
atin
g an
en
ablin
g en
viro
nmen
t fo
r pr
ivat
e se
ctor
-led
grow
th t
o ex
pand
em
ploy
men
t and
redu
ce p
over
ty
Mor
e w
omen
of r
epro
duct
ive
age
and
child
ren
bene
fit fr
om im
prov
ed a
cces
s to
qua
lity
heal
th
serv
ices
incl
udin
g ch
ild s
urvi
val s
ervi
ces.
Targ
eted
ben
efici
arie
s ha
ve im
prov
ed n
utrit
iona
l st
atus
Hea
lth w
orke
rs, e
spec
ially
wom
en, i
nse
lect
ed d
istri
cts
are
able
to p
rovi
de b
ette
r cur
ativ
e an
d pr
even
tive
serv
ices
on
the
basi
s of
a p
acka
ge o
f es
sent
ial s
ervi
ces.
Hea
lth a
nd n
utrit
ion
com
mun
icat
ion
stra
tegy
ad
apte
d, e
xpan
ded
and
impl
emen
ted
Com
mun
ities
and
targ
eted
fam
ilies
have
impr
oved
ca
paci
ty in
pro
cess
ing,
pre
para
tion
and
stor
age
of
food
Com
mun
ities
and
targ
eted
fam
ilies
have
impr
oved
aw
aren
ess
of n
utrit
iona
l val
ues
of lo
cally
ava
ilabl
e/in
trodu
ced
food
UN
TP c
apac
ity d
evel
opm
ent s
trate
gy
Hea
lth a
nd n
utrit
ion
com
mun
icat
ion
stra
tegy
UN
ICEF
/WH
O A
ccel
erat
ed Y
oung
Chi
ld
Surv
ival
Initi
ativ
e (A
YCS)
Key
obje
ctiv
e is
to
focu
s on
exp
andi
ng
acce
ss fo
r you
ng c
hild
ren
and
mot
hers
to
a ke
y se
t of c
ritic
al lif
e sa
ving
inte
rven
tions
im
med
iate
ly a
nd in
the
long
er te
rm.
(1) C
ontin
ue w
ith lif
e sa
ving
em
erge
ncy
inte
rven
tions
(2
) Ex
pand
acc
ess
to l
ife s
avin
g in
terv
entio
ns f
or
all
child
ren
thro
ugh
inst
itutio
naliz
ing
high
im
pact
po
pula
tion
orie
nted
ser
vice
s in
clud
ing
cam
paig
n an
d ou
treac
h m
odes
(3
) Ex
pand
ac
cess
an
d ut
ilizat
ion
of
the
basi
c he
alth
car
e sy
stem
thr
ough
incr
ease
d co
vera
ge o
f co
mm
unity
bas
ed s
ervi
ces
and
refe
rral
(4) U
se m
ass
and
inte
r-per
sona
l com
mun
icat
ions
to
prom
ote
posi
tive
beha
viou
ral c
hang
e an
d im
prov
ed
heal
th s
eeki
ng b
ehav
iour
s.
Chi
ld h
ealth
day
aim
to p
rovi
de 9
0 pe
r cen
t of u
nder
-fiv
es a
nd o
ver 6
0 pe
r cen
t of w
omen
of c
hild
bea
ring
age
natio
nwid
e w
ith
high
-impa
ct
child
su
rviv
al
inte
rven
tions
: im
mun
izat
ion
agai
nst
mea
sles
, po
lio,
diph
ther
ia,
pertu
sis
and
teta
nus
vi
tam
in
A su
pple
men
tatio
n, d
ewor
min
g, p
rovi
sion
of
oral
re
hydr
atio
n sa
lts,
wat
er t
reat
men
t ta
blet
s, h
ygie
ne
educ
atio
n, n
utrit
iona
l scr
eeni
ng, a
nd te
tanu
s to
xoid
va
ccin
atio
n fo
r wom
en;
Opp
ortu
nity
fo
r nu
tritio
n cl
uste
r to
pr
ovid
e in
puts
to
impr
ove
qual
ity a
nd c
over
age
of
nutri
tion
inte
rven
tions
pro
vide
d th
roug
h C
HD
ie
vita
min
A, d
ewor
min
g an
d nu
tritio
n sc
reen
ing
Tabl
e 2:
Exi
stin
g pr
ogra
mm
es p
rese
ntin
g op
port
uniti
es fo
r int
egra
ting
nutr
ition
act
iviti
es in
Som
alia
58 W
HO
/UN
ICEF
G
AVI
Hea
lth
Syst
em
Stre
ngth
enin
g St
reng
then
ing
of m
ater
nal
child
hea
lth c
entre
s &
heal
th p
osts
(40
MC
H +
80
heal
th p
osts
thro
ugho
ut
3 zo
nes)
Rec
ruitm
ent t
rain
ing
and
depl
oym
ent o
f 240
fem
ale
com
mun
ity h
ealth
wor
kers
(FC
HW
s)
Beha
viou
r Com
mun
icat
ion
Cha
nge
(BC
C) s
trate
gy
Ope
ratio
nal r
esea
rch
Thro
ugh
colla
bora
tion
with
he
alth
se
ctor
, nu
tritio
n co
mpo
nent
of
MC
H s
ervi
ces
can
be
stre
ngth
ened
– d
evel
opm
ent
of s
tand
ardi
sed
prot
ocol
s, c
ompr
ehen
sive
trai
ning
( pr
e-se
rvic
e an
d in
ser
vice
) su
perv
isio
n an
d m
onito
ring
in f
ollo
win
g ar
eas:
ass
essm
ent
of n
utrit
iona
l st
atus
, IYC
F an
d m
ater
nal n
utrit
ion
coun
sellin
g,
mic
ronu
trien
t tre
atm
ent
and
supp
lem
enta
tion,
pr
even
tion
and
cont
rol o
f dia
rrhoe
a
New
inno
vatio
n of
FC
HW
s ca
n be
trai
ned
as
brea
st fe
edin
g co
unse
llors
, to
prov
ide
nutri
tion
coun
sellin
g fo
r mot
hers
and
you
ng c
hild
ren,
the
dist
ribut
ion
of m
icro
nutri
ent
supp
lem
enta
tion,
pr
even
tion
and
cont
rol o
f dia
rrhoe
a ac
tiviti
es
Key
nutri
tion
mes
sage
s ca
n be
inc
orpo
rate
d in
to B
CC
stra
tegy
in p
artic
ular
rega
rdin
g op
timal
br
east
feed
ing,
com
plem
enta
ry fe
edin
g, g
ood
hygi
ene
and
hand
was
hing
pra
ctic
es
Ope
ratio
nal r
esea
rch
will
help
in e
valu
atio
n of
fe
asib
ility
and
effe
ctiv
enes
s
WH
O
Com
mun
ity
base
d In
itiat
ives
(C
BI)
CBI
pr
ogra
mm
es
aim
to
ad
dres
s he
alth
de
term
inan
ts
thro
ugh
inte
grat
ed
soci
oeco
nom
ic d
evel
opm
ent
with
act
ive
com
mun
ity in
volv
emen
t and
inte
r-sec
tora
l co
llabo
ratio
n.
Basi
c de
velo
pmen
t ne
eds-
fo
rmat
ion
of
villa
ge
deve
lopm
ent
com
mitt
ees
in
48
villa
ges
in
CSZ
, tra
inin
g of
cl
uste
r re
pres
enta
tives
, ne
eds
asse
ssm
ent &
prio
ritis
atio
n, p
roje
ct p
repa
ratio
n w
ith
loca
l sol
utio
ns, i
mpl
emen
tatio
n
Villa
ge d
evel
opm
ent c
omm
ittee
s and
repr
esen
tativ
es
in p
lace
and
trai
ned
with
loca
l prio
ritie
s an
d so
lutio
ns
for i
mpr
ovin
g he
alth
iden
tified
and
sen
sitis
ed.
Inte
r-sec
tora
l col
labo
ratio
n
Del
iver
y m
echa
nism
for k
ey n
utrit
ion
mes
sage
s an
d ad
voca
cy fo
r im
prov
ed IY
CF,
hyg
iene
and
sa
nita
tion
prac
tices
at t
he c
omm
unity
leve
l
59
Esse
ntia
l Pa
ckag
e of
Hea
lth S
ervi
ces
(EPH
S) fo
r Som
alia
200
8Th
e EP
HS
is t
he p
rime
mec
hani
sm f
or s
trate
gic
serv
ice
prov
isio
n of
the
publ
ic s
ecto
r hea
lth s
ervi
ce.
It he
lps
to c
larif
y he
alth
prio
ritie
s an
d di
rect
s re
sour
ce
allo
catio
n.
It de
fines
M
oH
resp
onsi
bilit
ies
and
activ
ities
at c
entra
l and
reg
iona
l lev
els,
par
ticul
arly
in
coo
rdin
atio
n, m
anag
emen
t an
d su
perv
isio
n of
se
rvic
es.
It cl
arifi
es t
he r
ole
com
mun
ities
pla
y in
cr
eatin
g a
sust
aina
ble
and
acco
unta
ble
heal
th
syst
em.
4 se
rvic
e le
vels
: i)
prim
ary
heal
th u
nit s
taffe
d by
1
train
ed
com
mun
ity
heal
th
wor
ker
who
co
nduc
ts
prom
otio
nal,
prev
entiv
e an
d cu
rativ
e ac
tiviti
es;
ii)
heal
th c
entre
- fir
st le
vel a
t whi
ch o
bste
tric
serv
ices
pr
ovid
ed; i
ii) re
ferra
l hea
lth c
entre
s an
d iv
) hos
pita
ls
offe
ring
6 co
re
prog
ram
mes
pl
us
3 ad
ditio
nal
prog
ram
mes
CH
Ws
can
be t
rain
ed i
n pr
omot
ion
of g
ood
nutri
tion,
fe
edin
g,
hygi
ene
and
sani
tatio
n pr
actic
es,
dist
ribut
ion
of
mic
ronu
trien
t su
pple
men
tatio
n to
w
omen
an
d ch
ildre
n,
cont
rol o
f dia
rrhoe
al d
isea
se in
clud
ing
OR
S &
10-1
4 da
ys z
inc
treat
men
t. N
utrit
ion
scre
enin
g an
d re
ferra
l,
MC
H, h
ealth
cen
tre a
nd h
ospi
tal s
taff
train
ed
and
supe
rvis
ed to
pro
vide
all
the
abov
e
WH
O/U
NIC
EF/U
NFP
A R
epro
duct
ive
Hea
lth S
trat
egy
Thre
e St
rate
gic
prio
ritie
s fo
r act
ion:
i) M
akin
g pr
egna
ncy
and
child
birth
saf
erii)
Pro
mot
ing
heal
thy
fam
ilies
iii) P
rom
otin
g be
nefic
ial
and
addr
essi
ng
harm
ful p
ract
ices
Impr
ove
acce
ss, a
vaila
bilit
y an
d qu
ality
of M
ater
nal
and
Neo
nata
l Hea
lth s
ervi
ces
Impr
ove
affo
rdab
le re
ady
acce
ss to
goo
d qu
ality
bi
rth s
paci
ng s
ervi
ces
for m
en a
nd w
omen
.
Stre
ngth
en a
war
enes
s am
ong
the
popu
latio
n of
th
e po
sitiv
e he
alth
ben
efits
of
certa
in t
radi
tiona
l pr
actic
es.
Incr
ease
nu
mbe
rs
of
qual
ified
m
idw
ives
an
d co
mm
unity
mid
wiv
es a
vaila
ble
for p
ublic
sec
tor i
n al
l th
ree
zone
s.
Prom
otio
n of
AN
C v
isits
, hom
e vi
sits
and
indi
vidu
al
coun
sellin
g by
CH
Ws
Prom
otio
n of
exc
lusi
ve b
reas
tfeed
ing
by C
HW
Stre
ngth
en a
war
enes
s of
ben
efits
of e
xclu
sive
and
pr
olon
ged
brea
stfe
edin
g
Esta
blis
h co
ntin
uous
po
st-b
asic
an
d co
mm
unity
m
idw
ifery
cou
rses
in a
ll th
ree
zone
s.
Del
iver
y m
echa
nism
fo
r m
ater
nal
nutri
tion
inte
rven
tions
, cou
nsel
ling
and
supp
ort f
or IY
CF
Mul
tiple
cha
nnel
s m
ultip
le c
onta
cts
Incl
usio
n of
nu
tritio
n tra
inin
g m
odul
es
for
mid
wiv
es
EU a
nd F
AO
Inte
grat
ed S
uppo
rt to
Rur
al
Live
lihoo
d w
ith th
e ai
m o
f miti
gatin
g th
e ef
fect
s of
soa
ring
food
pric
es f
or 7
8,10
0 ho
useh
olds
in S
outh
Cen
tral S
omal
ia
Vuln
erab
le ru
ral s
mal
lhol
ders
to b
enefi
t fro
m in
com
e ge
nera
ting
activ
ities
, inc
reas
ed le
vels
of p
rodu
ctio
n an
d in
crea
sed
avai
labi
lity
of a
gric
ultu
ral
prod
ucts
in
th
e lo
cal
mar
kets
. Pl
us
the
reha
bilit
atio
n of
in
frast
ruct
ure-
can
als,
mar
ket p
lace
s an
d ro
ads.
Enha
ncin
g ag
ricul
tura
l pro
duct
ion
thro
ugh
cash
for
wor
k pr
ogra
mm
es,
dist
ribut
ion
of p
acka
ged
seed
ki
ts, t
ools
and
ferti
lizer
s
Impr
oved
live
lihoo
d an
d fo
od s
ecur
ity s
houl
d ha
ve p
ositi
ve im
pact
on
nutri
tiona
l sta
tus
FAO
Tria
ls o
f Im
prov
ed P
ract
ices
pilo
t in
Hira
n an
d G
edo
iden
tified
by
KAP
stud
y as
be
ing
parti
cula
rly v
ulne
rabl
e in
IYC
F
This
pro
ject
aim
s to
iden
tify
and
impl
emen
t the
mos
t ac
cept
able
pra
ctic
es in
the
regi
on in
impr
ovin
g in
fant
an
d ch
ild f
eedi
ng p
ract
ices
. Th
e m
etho
d in
volv
es
disc
ussi
on
with
th
e m
othe
rs
and
care
give
rs
in
mov
ing
tow
ards
rec
omm
ende
d IY
CF
over
thr
ee
hous
ehol
d vi
sits
.
Mov
e fro
m id
eal I
YCF
reco
mm
enda
tions
to p
ract
ical
re
com
men
datio
ns.
Pilo
t in
Ged
o an
d H
iran
can
be s
cale
d up
in
othe
r are
as
60
In this section, internationally recognised, proven effective interventions are linked with the priorities identified for Somalia and what is feasible in the context.
Outcome 1 Improved access to and utilisation of quality services for the management of malnutrition in women and children
The Lancet series on Maternal and Child undernutrition (2008) highlights that recent studies demonstrate new commodities such as ready to use therapeutic food (RUTF) can be used effectively to manage severe acute malnutrition in community settings. The Community based management of acute malnutrition (CMAM) approach increases the number of children who can be treated, reduces exposure to disease and reduces drop-out rates compared to standard management of acute malnutrition approach using therapeutic milks in a centre based setting (Collins et al 2006).
The development of RUTF and the CMAM approach has opened the door to significant expansion of services for the management of severe acute malnutrition in Somalia where the weak health infrastructure and high insecurity have been major challenges to centre based management. Since 2006, 250 OTPs supported by UNICEF have opened. Some coverage gaps remain particularly with respect to access to stabilisation centres or adequate facilities for referral of complicated cases. This is especially so in South Central Somalia where the majority of SAM cases live but humanitarian space is most limited. Quality of services is also an issue. Thus, the enhancement and expansion of quality interventions for the management of acute malnutrition in accordance with newly developed guidelines remains a priority. Whilst poor coverage of referral centres continues to be a major constraint to providing quality services, the promotion of community mobilisation as a key activity of all OTPs is an important approach to improving coverage and early diagnosis to reduce the presentation of complicated cases in need of referral. As it is such a key activity in this context, community mobilisation requires dedicated staff and resources.
The results of the micronutrient and anthropometric survey 2009 underscore the importance of scaling up services for the treatment of micronutrient deficiencies. Treatment services are currently limited by weakness in the health system and by poor access to and utilisation of health facilities. However, while not a remit of this strategy, health system strengthening is an overarching goal. The development of simple Somali specific standardised protocols in conjunction with pre-service and in service training modules on diagnosis and treatment of MND for all health staff, and commitment to timely provision of supplies, will contribute to improving treatment services.
JUSTIFICATION OF OUTCOMES AND KEY APPROACHES ADOPTED IN THIS STRATEGY
ANNEX 3
Child eating Plumpynut Save the Children, Somaliland
61 Management of malnutrition also involves its prevention. As highlighted in the section on outcome 2, behaviour change communication strategies to improve complementary feeding practices have been proven effective in improving growth outcomes in young children. However, as the Lancet series on undernutrition concluded, such strategies alone were of most benefit in populations that had sufficient means to procure appropriate food. In food insecure populations, nutrition education had a greater impact when food or food supplements were provided. Furthermore, the recent review of complementary feeding (Dewey and Adu-Afarwuah 2008) found that interventions in which micronutrient supplementation alone was provided generally had little or no effect on growth.
This strategy includes key outputs for addressing longer term goals of improving diet diversity and increasing consumption of local nutrient dense foods. However, in the meantime the evidence cited above underscores the importance of providing food based interventions to meet energy and protein, as well as micronutrient, requirements for the prevention of undernutrition in high risk areas of food insecurity in Somalia. In these areas where locally available foods alone will not satisfy nutritional requirements, additional food products can fill a critical gap in nutrients as a complement to continued breastfeeding and the local diet, not as a replacement. Thus food based interventions will be accompanied by counselling on continued breastfeeding, responsive feeding and good hygiene practices.
The review by Dewey and Abu-Afarwuah (2008) also found that in several studies the impact of providing a complementary food in combination with nutrition education was evident only in the younger children. This reiterates the ‘critical window of opportunity’ and the importance of targeting food based interventions to prevent undernutrition in the 6 to 24 months age group.
In Somalia the options for products for food based interventions are corn soy blend (CSB) or the new lipid-based nutrient supplements (LNS). LNS are a range of products fortified with multiple micronutrients and in which lipid is the primary source of energy. There are pros and cons to both types of products. Blended food has long been used in Somalia. Its acceptability is proven, it is cheap and there are limited pipeline issues. On the negative side, the efficacy of blended food has more recently been questioned with varied results achieved. The energy density of blended food is low compared to the stomach capacity of a small child. The high phytate content of the current CSB inhibits micronutrient absorption while there is a lack of animal protein. Furthermore there are two factors of the Somali context which further reduce the efficacy of CSB. Firstly, it is rarely possible to premix blended food with oil and sugar therefore energy density is compromised. Secondly, limited supervision is possible and weak supervision has been demonstrated to reduce success (Navarro-Colorado et al 2008)). In addition, a recent review article found evidence of the efficacy of fortified blended foods for improving nutritional outcomes to be currently limited and weak (Perez-Exposito and Klein 2009). Two new products under development, CSB+ (pregnant & lactating women, children 2-5 years) and CSB++ (children under two), may improve the effectiveness of blended food in the future.
Child eating Plumpydoz, IDP camp Jowhar, UNICEF Somalia
62 The advantages of LNS pertinent to the Somali context include: LNS are high quality fortified foods that can be used at home without the need for water or premixing or cooking; they are stable and resistant to spoilage, the micronutrients do not interact; they provide additional energy and increase energy density of complementary foods; they have been proven to improve linear growth of young children and proven more effective than CSB in supplementary feeding of moderately malnourished children (Nackers et al 2010). LNS in the form of the product ‘Plumpy Doz’ has been used in Somalia under operational research conditions. However with high prevalence of acute malnutrition and limited contacts with beneficiaries, evaluating and documenting impacts have proved difficult. Thus cost compared to nutritional benefit is as yet undetermined in the context.
Outcome 2 Sustained availability of timely and quality nutrition information and operational research into effective responses to the causes of undernutrition
Quality and timely nutrition information is essential to defining appropriate & feasible nutrition response options. Whilst more is known about the underlying causes of undernutrition throughout Somalia from KAPs 2007, the national micronutrient and Anthropometric Survey 2009, FSNAU data, less is known about the types of interventions that can impact on the problem, particularly in the Somali context. Operational research is therefore key to providing the evidence base on which appropriate programmes can be planned.
Outcome 3 Increased appropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition
KAPS 2007 and Micronutrient survey 2009 reveal the extent of inappropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition throughout Somalia. Rates of exclusive breastfeeding are extremely low at around 5% (National Micronutrient and Anthropometric Nutrition survey 2009). According to KAPS 2007, the practice of discarding colostrum is widespread. Infant formulas are vigorously promoted in a context of widespread poor water, sanitation and hygiene conditions. In contrast, the Lancet series on Maternal and Child Undernutrition 2008 identifies that exclusive breastfeeding in the first six months of life is particularly beneficial while infants who are not breastfed in the first month of life may be as much as 25 times more likely to die than infants who are exclusively breastfed. Continued breastfeeding is also very critical to improve feeding in children 6-23 months of age, as breast milk is an important source of energy and nutrients in the child’s diet.
The Lancet series on Maternal and Child Undernutrition 2008 shows that both individual and group counselling have been demonstrated to extend the duration of exclusive breastfeeding. In Somalia individual counselling of mothers on appropriate breastfeeding practices and improving family and community understanding and support for early initiation and exclusive breastfeeding to six months are important. However, the other key priority is to address the vigorous advertising of breast milk substitutes by engaging with importers and traders. While the absence of a legislative framework is appreciated, it is important that a longer term consultative process on adoption of the International code for marketing of Breast milk substitutes is initiated.
Poor infant and young child feeding practices, including bottle-feeding in deplorable conditions is a predisposing factor to diarrhoea and malnutrition, FSNAU, Dec, 2009
63 As highlighted in the situation analysis young child feeding practices in Somalia tend to be inadequate, with only one in ten children being appropriately fed. Energy density of complementary feeds is low and diet diversity poor. A recent review of 42 efficacy trials and effectiveness studies on complementary feeding interventions concluded that carefully designed programmes that include pre-tested educational messages provided through multiple channels had an effect in improving complementary feeding. A greater impact was seen when animal-source foods were specifically promoted in the messages or when food supplements were provided as well. Educational strategies should focus on imparting the knowledge and develop skills to maximise use of locally-available, high-quality foods, as well as food safety, cultural beliefs and intra-family food distribution. As recommended in the review, this strategy aims to deliver nutrition counselling through multiple channels, individual, community and mass media integrated into the programmes that reach mothers and children ie nutrition programmes, schools, community based initiatives and MCH and outreach services. The integration of support for IYCF into the CMAM approach, piloted in Sierra Leone and Zimbabwe by UNICEF & Save the Children UK may be a useful model to adapt to Somalia.
Outcome 4 Improved availability and coverage of micronutrients and de-worming interventions to the population
Micronutrient malnutrition has wide-ranging effects on health, learning ability and productivity and has high social and public costs leading to reduced work capacity due to high rates of illness and disability. As highlighted in the situational analysis, prevalence of both nutritional anaemia and vitamin A deficiency in women and children in all three zones of Somalia are above WHO thresholds for the classification of a severe situation. There are different approaches to preventing micronutrient malnutrition. The best way is to ensure the consumption of a balanced diet but this requires universal access to adequate food and appropriate dietary habits, neither of which reflect the current scenario in Somalia, and both of which are complex and long term issues to address. In the shorter term, micronutrient supplementation and food fortification and deworming have been proven both highly effective and low cost interventions. With their high benefit to cost ratio, these interventions have been identified as among the top ten cost-effective solutions to global challenges (Copenhagen Consensus 2008).
In Somalia, bi annual vitamin A supplementation and deworming are currently key components of child health days, multiple micronutrient supplementation for pregnant and lactating women is available through MCH. Activities identified in this strategy aim to strengthen these existing interventions and to develop new approaches to increase coverage through novel population based strategies eg through schools and nutrition programme beneficiaries.
Another novel approach identified in this strategy is the fortification of food, in particular cereal flours. Food fortification is able to deliver nutrients to the population without requiring changes in food consumption patterns. It is usually socially acceptable, requires no change in food habits, can produce nutritional benefits for the target population quickly and is a safe, cost-effective way of reaching large target populations (WHO FAO Guidelines on Food Fortification with Micronutrients 2006). Also food fortification can provide nutrients that are not obtainable in sufficient doses from local foods, such as folic acid for the prevention of birth defects. This new area for Somalia will require preliminary work before going to scale. With nearly half the population receiving humanitarian food assistance, the fortification of grains distributed through the general food ration is a priority. Furthermore as even in a good year, Somalia imports 60% of its cereal requirement, fortification of imported cereal flours presents an important vehicle for improving the micronutrient intake of a significant proportion of the population. Fortification of flour at the community level may be a useful approach in low access areas.
64 Outcome 5 Nutrition is mainstreamed as a key component of health, WASH, livelihoods, food aid and education sectors
This outcome reflects the multiple and overlapping causes of undernutrition in Somalia which require a multi sectoral response if longer term improvement in nutritional status, survival and development are to be achieved. Providing one intervention in isolation of others minimises its potential benefits and represents a missed opportunity of contact with the population. As existing structures and capacity in Somalia are weak and limited and access to and utilisation of services low, the integration and enhancement of nutrition activities within multi sector programmes is even more paramount. In health in particular, as stated in the World Bank paper, Repositioning Nutrition as Central to Development nutrition should be “included as a core function of services and not as an adjunct activity to be implemented by lower level health professionals or only when time permits”.
Activities within this strategy are aimed at mainstreaming nutrition within government as well as non government structures. Increasing awareness within the line ministries of the importance of nutrition as a key determinant of health and development will be an important step to keeping nutrition on the agenda in Somalia in the longer term.
Outcome 6 Improved capacity and means in country to deliver essential nutrition services
The situational analysis highlights the low capacity and means in country to deliver essential nutrition services. The health system is weak and fragmented, qualified professionals have left the country or moved to the private sector. Nutrition capacity within the regional authorities is limited. Thus the need to build local capacity to respond in the short and longer term is undeniable. Ideally this would encompass all levels, all sectors, government and non government structures. The Lancet series on undernutrition highlights that “governments must build internal capacity dedicated to addressing undernutrition to achieve longer lasting changes”. In the context of Somalia this is more challenging and thus key output of this strategy is to support the development of a local body responsible for addressing nutrition issues locally while government structures emerge and develop. Capacity development is not purely about training and organisation strengthening but also about building local ownership.
The development of a nutrition capacity development strategy which is linked to the UNTP plan for capacity development is an important step to identifying priorities and advocating for funding. Capacity development is needed not specifically in technical competencies but in cross cutting issues of work management, community mobilisation, team building, adopting an ethical approach, professional development. The aim is not to develop a dedicated body of highly specialised nutritionists but instead to develop relevant nutrition skills among all health workers and programmes staff from all sectors including community workers, agricultural extension workers, school teachers. Thus working with pre service training institutions for the incorporation of appropriate nutrition training modules into existing professional training curricula is a priority. The development of regional training/mentoring cells is an innovative approach to overcome challenges of limited access and supervision capacity on the ground and high staff turn over, while creating an enabling environment for partners to operate effectively is for many organisations on the ground with very limited access to resources, an important first step.
65 Annex 4 Proven Effective interventions for maternal and child malnutrition (Taken from The Lancet Series on Maternal and Child Undernutrition Executive Summary January 2008)Annex 4 Proven Effective Interventions for Malnutrition and Child Malnutrition
Sufficient evidence for
implementation in all 36 countries
Maternal and birth outcomes
Iron folate supplementation
Maternal supplements of multiple micronutrients
Maternal iodine through iodisation of salt
Maternal calcium supplementation
Interventions to reduce tobacco
consumption or indoor air pollution
Newborn babies
Promotion of breastfeeding (individual
and group counselling)
Infants and children
Promotion of breastfeeding (individual
and group counselling)
Behaviour change communication for
improved complementary feeding*
Zinc supplementation
Zinc in the management of diarrhoea
Vitamin A fortification or supplementation
Universal salt iodisation
Handwashing or hygiene interventions
Treatment of severe acute malnutrition
Evidence for implementation in
specific situational contexts
Maternal supplements of balanced
energy and protein
Maternal iodine supplements
Maternal deworming in pregnancy
Intermittent preventive treatment for malaria
Insecticide-treated bednets
Neonatal vitamin A supplementation
Delayed cord clamping
Conditional cash transfer programmes
(with nutrition education)
Deworming
Iron fortification and supplementation programmes
Insecticide-treated bednets
66 Annex 5 Copenhagen Consensus 2008: results
RANK SOLUTION1 Micronutrient supplements for children (vitamin A and zinc)2 The Doha development agenda3 Micronutrient fortification4 Expanded immunisation coverage for children 5 Biofortification6 Deworming and other nutrition programmes at school7 Lowering the price of schooling8 Increase and improve girl’s schooling9 Community based nutrition promotion10 Provide support for women’s reproductive role (Ref Horton et al 2008)
67 Annex 6 How Malnutrition affects achievement of MDGs
Goal Nutritional Effect
Annex 6 How malnutrition affects achievement of the MDGs
GOAL
Goal 1: Eradicate extreme poverty and
hunger
Goal 2: Achieve universal primary education
Goal 3: Promote gender equality and
empower women
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat HIV/AIDS, malaria and other diseases
Source: World Bank paper:
Repositioning Nutrition as Central to Development
NUTRITION EFFECT
Malnutrition erodes human capital
through irreversible and
intergenerational effects on cognitive and physical development
Malnutrition affects the chances that a child will go to school, stay in school
and perform well
Antifemale biases in access to food,
health, and care resources may result
in malnutrition, possibly reducing women’s access to assets. Addressing
malnutrition empowers women more
than men.
Malnutrition is directly or indirectly
associated with most child deaths and
it is the main contributor to the burden of disease in the developing world
Maternal health is compromised by malnutrition which is associated with
most major risk factors for maternal
mortality. Maternal stunting and iron
and iodine deficiencies particularly pose serious problems
Malnutrition may increase risk of HIV transmission, compromise
antiretroviral therapy and hasten onset
of full-blown AIDS and premature
death. It increases the chances of tuberculosis infection resulting in
disease and also reduces malaria
survival rates
68 Key ReferencesBhutta ZA, Ahmed T, Black RE et al. Maternal and Child Undernutrition 3: What works? Interventions for maternal and child undernutrition and survival. The Lancet Series, Vol. 371, published online 17th January 2008
Collins S, Dent N, Binns P. Management of severe acute malnutrition in children. Lancet 2006; 368: 1992-2000
Dewey K, Adu-Afarwuah S. Review article: Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Maternal and Child Nutrition, 2008, 4:24-85.
ENN, IFE Core Group, ISAC Integration of IYCF support into CMAM Facilitators Guide and Handouts. ENN October 2009
FSAU Somali Knowledge Attitude and Practices Study (KAPS) Infant and Young Child Feeding and Health Seeking Practices December 2007,
FSNAU Technical Series report No. V. 17 2008/09 Post Deyr Analysis
FSNAU Technical Series report No. VI. 25 Nutrition Situation Post Gu 2009
FSNAU Technical Series report No. VI. 30 Nutrition Situation Post Deyr 09/10
FSNAU Nutrition Trends in Somalia (2001-2008) A Meta analysis study report (DRAFT)
Horton S, Alderman H, Rivera JA, Copenhagen Consensus 2008 Challenge Paper: Hunger and Malnutrition, Copenhagen Consensus Center, May 2008
Ibrahim MM, Persson LA, Omar MM & Wall S. Breast feeding and the dietary habits of children in rural Somalia. Acta Paediatrica 1991; 81: 480-483
Nackers F, Broillet F, Oumarou D, Djibo A, Gaboulaud V, Guerrin PJ, Rusch B et al Effectiveness of ready-to-use therapeutic food compared to a corn/soy-blend-based pre-mix for the treatment of childhood moderate acute malnutrition in Niger. J Trop Paed (2010) doi:10.1093/tropej/fmq019
Navarro-Colorado C, Mason F and Shoham J (2008) Measuring the effectiveness of Supplementary Feeding Programmes in emergencies HPN ODI network paper number 63 September 2008 Perez-Exposito AB and Klein BP. Impact of fortified blended food aid products on nutritional status of infants and young children in developing countries. Nutrition Reviews Vol. 67(12):706–718
Rossi L and Davies A. Exploring Primary Health Care in Somalia: MCH Data 2007. UNICEF Somalia Support Centre Report 8
Sadler, K., Kerven, C., Calo, M., Manske, M. & Catley, A. (2009), Milk Matters: A literature review of pastoralist nutrition and programming responses. Feinstein International Centre, Tufts University and Save the Children. Addis Ababa.
Shrimpton, Roger, Cesar G. Victora, Mercedes de Onis, Rosângela Costa Lima, Monika Blössner, and Graeme Clugston. 2001. “The Worldwide Timing of Growth Faltering: Implications for Nutritional Interventions.” Pediatrics 107: e75.
UNICEF Essential Package of Health Services (EPHS), 2009 revision + annexes
UNICEF Somalia Multiple Indicator Cluster Survey (MICS) 2006
United Nations Transition Plan for Somalia 2008-2009
WHO/FAO Guidelines for Food Fortification with micronutrients November 2006
WHO UNFPA UNICEF Somalia Reproductive Health National Strategy and Action Plan 2009
WHO\UNICEF Initiative for Accelerated Young Child Survival 2008-2009
WFP Somalia Puntland Food Security and Vulnerability Assessment April 2007
WFP Somalia Somaliland Food Security and Vulnerability Assessment August 2008
World Bank Repositioning Nutrition as Central to Development, a strategy for large scale action, World Bank 2006, ISBN-10:0-8213-6399-9
Young H and Jaspers S (2006) The meaning and measurement of acute malnutrition in emergencies: A primer for decision makers. HPN ODI network paper number 56 November 2006
“Individual country nutrition strategies and programmes, while drawing on international evidence of good practice,
must be country - ‘owned’ and built on the country’s specific needs and capacities.”
Scaling up nutrition (SUN) - A Framework for Action, Sept. 2010