10. transición de la nutrición a nivel global
TRANSCRIPT
The Nutrition Transition Globally:
Alternative Solutions
15 May 2015
Martin Bloem
2
The need for both nutrition specific and nutrition
sensitive interventions is well recognized…
Interventions or programmes that address
the immediate determinants
1. adequate food and nutrient intake,
feeding,
2. infectious diseases
Interventions or programmes that address
the underlying determinants
1. food security;
2. adequate care-giving resources
3. access to health services and a safe
and hygienic environment
Nutrition specific interventions Nutrition sensitive interventions
Ruel et al. 2013
3
Lancet Series in 2013 framework, including nutrition
specific and sensitive interventions & approaches
4
Multisectoral, multistakeholder efforts required to
address malnutrition G
lob
al
pro
cess
es Regional/global processes supporting national nutrition efforts
Go
v’t
effo
rts
National governments prioritizing nutrition efforts
Health Agriculture &
fisheries Social
development Finance
Oth
er s
take
ho
lder
s
Donors UN* NGOs / CSOs Private sector Academia
Education
* UN Nutrition Network comprised of FAO, UNICEF, WFP, WHO and IFAD; other agencies engaged in nutrition include UNHCR, UNFPA, UN Women, and UNDP
Stakeholder landscape for nutrition – not exhaustive
5
SGA, Mortality and Undernutrition
6
WFP’s focus
(1) Micronutrient powders (2) Provides kcal, protein, essential fatty acids and micronutrients (3) Micronutrient deficiencies (4) Sexual reproductive health (5) Folic acid, multiple micro-nutrients, Calcium, Iron / iron + folate, Iodine (6) multiple micro-nutrients
Adolescents Pregnancy Lactation /
Neonates
Infants and
Children
Meeting micronutrient
requirements
• Fortified foods
• Supplements or school
meal fortification
(MNPs1)
Food support (e.g.
school feeding)
Meeting micronutrient
requirements
• Specialized nutritious
foods2
• Treatment of MAM
Food support in the
last trimester
Meeting micronutrient
requirements
• Specialized nutritious
foods2
Food support during
lactation (first 6
months)
Prevention of under-
nutrition
• Complementary
foods2 (6-23 months)
Treatment of MAM
• Supplementary
foods2 (6-59 months)
Addressing MNDs3
Ro
le o
f W
FP
Inte
rve
nti
on
s b
as
ed
on
La
nc
et
evid
en
ce
& S
UN
Raise awareness about the importance of health and nutrition
7
…but implementation is complex and requires broad
stakeholder involvement
(1) Micronutrient powders (2) Provides kcal, protein, essential fatty acids and micronutrients (3) Micronutrient deficiencies (4) Sexual reproductive health (5) Folic acid, multiple micro-nutrients, Calcium, Iron / iron + folate, Iodine (6) multiple micro-nutrients
Adolescents Pregnancy Lactation /
Neonates
Infants and
Children
• Supplements
• Preconception
health and nutrition
• Family planning
• SRH4 awareness
• Delayed age at
marriage & first
pregnancy
• Prolonging inter-
pregnancy interval
• Abortion care
• Early enrollment in
prenatal care
• Disease prevention
(malaria, obesity,
deworming)
• Family planning /
birth spacing
• Tobacco cessation
• Bfding counseling
• Psychosocial care
• Supplementation5
• Delayed cord
clamping
• Early initiation &
continued bfding
feeding (exl 6 mos)
• Vitamins A & K for
newborns
• Supplementation4
• Early enrollment in
post-natal care
• Skin-to-skin contact
• Exclusive
breastfeeding
• Management of
SAM
• Water, Sanitation
and Hygiene
(WASH)
• Disease prevention
(malaria, obesity)
• Deworming
• Supplementation6
Meeting micronutrient
requirements
• Fortified foods
• Supplements or school
meal fortification
(MNPs1)
Food support (e.g.
school feeding)
Meeting micronutrient
requirements
• Specialized nutritious
foods2
• Treatment of MAM
Food support in the
last trimester
Meeting micronutrient
requirements
• Specialized nutritious
foods2
Food support during
lactation (first 6
months)
Prevention of under-
nutrition
• Complementary
foods2 (6-23 months)
Treatment of MAM
• Supplementary
foods2 (6-59 months)
Addressing MNDs3
Ro
le o
f o
ther
part
ne
rs/s
tak
eh
old
ers
R
ole
of
WF
P
Inte
rve
nti
on
s b
as
ed
on
La
nc
et
evid
en
ce
& S
UN
Raise awareness about the importance of health and nutrition
8
…but implementation is complex and requires broad
stakeholder involvement - nutrition sensitive interventions
Health WASH Education Agriculture Social Dev’t
• Food assistance
to enable uptake
of services
(maternal health,
MAM treatment,
HIV treatment)
• Incorporating
nutrition and SRH
into School
Feeding prgms
• Innovative
distribution
modalities (e.g.,
Cash and
Vouchers)
MAM: Moderate acute malnutrition; WASH: Water, sanitation and hygiene; CHAI: Clinton Health Access Initiative; P4P: Purchase for Progress; FFW/A: Food for Work/Assets
WFP
lead
ing
Partn
ers le
adin
g
Nutrition sensitive: incorporating nutrition into other sector approaches to achieve improved nutrition outcomes
9
…but implementation is complex and requires broad
stakeholder involvement - nutrition sensitive interventions
Health WASH Education Agriculture Social Dev’t
• Food assistance
to enable uptake
of services
(maternal health,
MAM treatment,
HIV treatment)
• Incorporating
nutrition and SRH
into School
Feeding prgms
• Innovative
distribution
modalities (e.g.,
Cash and
Vouchers)
• Behaviour
change
communication
• Staff trainings on
WASH essentials
• Asset creation
• Incorporating
nutrition and SRH
into adolescent
girls groups
• Behaviour
change
communication
• Ag. and market dev’t (P4P)
• Maximizing nutritional
benefits of ag. value chains
• Livelihoods, economic
empowerment of
smallholders and women
(FFW/A, P4P)
• Processing (fortification,
safety)
• Advocating for and
designing explicit
nutrition
objectives and
outcomes within
social protection
programmes
MAM: Moderate acute malnutrition; WASH: Water, sanitation and hygiene; CHAI: Clinton Health Access Initiative; P4P: Purchase for Progress; FFW/A: Food for Work/Assets
WFP
lead
ing
Partn
ers le
adin
g
Nutrition sensitive: incorporating nutrition into other sector approaches to achieve improved nutrition outcomes
10
…but implementation is complex and requires broad
stakeholder involvement - nutrition sensitive interventions
Health WASH Education Agriculture Social Dev’t
• Food assistance
to enable uptake
of services
(maternal health,
MAM treatment,
HIV treatment)
• Incorporating
nutrition and SRH
into School
Feeding prgms
• Innovative
distribution
modalities (e.g.,
Cash and
Vouchers)
• Behaviour
change
communication
• Staff trainings on
WASH essentials
• Asset creation
• Incorporating
nutrition and SRH
into adolescent
girls groups
• Behaviour
change
communication
• Ag. and market dev’t (P4P)
• Maximizing nutritional
benefits of ag. value chains
• Livelihoods, economic
empowerment of
smallholders and women
(FFW/A, P4P)
• Processing (fortification,
safety)
• Advocating for and
designing explicit
nutrition
objectives and
outcomes within
social protection
programmes
• Family planning
and reproductive
health services
• Improving access
to water,
sanitation and
hygiene
• Including nutrition
in educational
policies
• Introducing
nutrition courses
in universities
• Increasing and
diversifying production
• Delivering
complementary
nutrition-
sensitive
package
MAM: Moderate acute malnutrition; WASH: Water, sanitation and hygiene; CHAI: Clinton Health Access Initiative; P4P: Purchase for Progress; FFW/A: Food for Work/Assets
WFP
lead
ing
Partn
ers le
adin
g
Nutrition sensitive: incorporating nutrition into other sector approaches to achieve improved nutrition outcomes
11
Nutrition activities focused
on vulnerable groups1,
including people living
with HIV and TB
Treatment of acute
malnutrition
WFP Nutrition Strategy
1 Prevention of
undernutrition 2
Enabling environment:
Technical Assistance and Advocacy with governments and other stakeholders
WASH Social
protection Agriculture
Ensure relevant sectors contribute to improved nutrition outcomes
Health
3
WFP’s Nutrition Policy supports improved nutrition
outcomes among vulnerable groups
Moderate acute
malnutrition Acute malnutrition*
Stunting*
Micronutrient deficiencies
*Prevention of acute malnutrition and stunting are not mutually exclusive, as ensuring adequate nutrition during the first 1000 days contributes to prevention of stunting,
acute malnutrition and micronutrient deficiencies. 1. Includes adolescent girls, PLW, 6-23 mo old children, chronically ill and other vulnerable individuals such as
disadvantaged school children, general population affected by emergencies; SRH: Sexual and reproductive health WASH: Water, Sanitation and Hygiene
Education
Food assistance as enabler for uptake
Behaviour change, staff trainings
Explicit nutrition objectives and
outcomes
Diversification, livelihoods, processing: fortification,
food safety
Behaviour change, school feeding, SRH
12
WFP has an important role to play in overcoming global
bottlenecks to improved nutrition outcomes w/ partners
Adolescent girls
Pregnant and lactating
women
Children 6-23 mo
• Meeting micronutrient requirements
• Food support (i.e., school feeding as an enabler for uptake of services)
• Meeting micro nutrient requirements
• Food support in last trimester and first six months of lactation
• Treatment of MAM
• Prevention of undernutrition and stunting
Difficulty of reaching most at-risk girls (e.g., married, not in school) with nutrition and SRH education
Programming gap in providing food support to PLWs in food insecure areas
• Lack of access to safe, high quality, nutritious complementary foods to fill the ‘nutrient gap’ for young children
• Governments are reluctant to import good quality comp. foods
• Partnership with UNICEF, UNFPA – adolescent girls and pregnant women
• Nutrition for MNCH in emergencies – PLW, children 6-23 mo
• Increasing access to complementary foods – children 6-23 mo (partnership with CHAI)
Nutrition interventions Global bottlenecks WFP’s contribution
13
Adolescent girls are a critical population in efforts to
reduce maternal and newborn mortality and stunting
P R E G N A N C Y
1st Trimester
2st Trimester 3rd Trimester DEL
IVER
Y
A D O L E S C E N C E
HEALTH FACILITY
FAMILY / COMMUNITY
SCHOOLS
FO
CU
S TI
ME
PER
IOD
S
TH
EOR
Y O
F C
HA
NG
E
Improved nutrition for all adolescent girls
MATERNITY WAITING HOMES
INDIVIDUAL & HOUSEHOLD LEVEL INTERVENTIONS
Beyond good health and nutrition for the next generation, nutrition for adolescents is also important for their own health and potential and for being a good parent
14
Adolescent girls are a critical population in efforts to
reduce maternal and newborn mortality and stunting
P R E G N A N C Y
1st Trimester
2st Trimester 3rd Trimester DEL
IVER
Y
A D O L E S C E N C E
HEALTH FACILITY
FAMILY / COMMUNITY
SCHOOLS
FO
CU
S TI
ME
PER
IOD
S
TH
EOR
Y O
F C
HA
NG
E
Improved nutrition for all adolescent girls
Improved nutrition during pregnancy
MATERNITY WAITING HOMES
INDIVIDUAL & HOUSEHOLD LEVEL INTERVENTIONS
Beyond good health and nutrition for the next generation, nutrition for adolescents is also important for their own health and potential and for being a good parent
15
Adolescent girls are a critical population in efforts to
reduce maternal and newborn mortality and stunting
P R E G N A N C Y
1st Trimester
2st Trimester 3rd Trimester DEL
IVER
Y
A D O L E S C E N C E
HEALTH FACILITY
FAMILY / COMMUNITY
SCHOOLS
FO
CU
S TI
ME
PER
IOD
S
TH
EOR
Y O
F C
HA
NG
E
Improved nutrition for all adolescent girls
Improved nutrition during pregnancy
• Reduced stunting & SGA • Reduced maternal &
newborn mortality
MATERNITY WAITING HOMES
INDIVIDUAL & HOUSEHOLD LEVEL INTERVENTIONS
Beyond good health and nutrition for the next generation, nutrition for adolescents is also important for their own health and potential and for being a good parent
16
Health 4+ / H4+
WFP’s contribution similar to the UNAIDS model
− Nutrition services integrated into RMNCH programs and platforms that reach
adolescent girls
− Delivery channels leveraged depending on country context and needs
Existing platforms with partners need to be leveraged
for WFP to add a nutrition component
Harnesses the collective power of each of the
six agencies and 53 countries to improve the
health of women and children
Global movement by UNSG to improve the
health of women and children
Launched by UNFPA to reach the most
marginalized adolescent girls
(1) IHP+ is a group of partners committed to improving the health of citizens in developing countries. International organizations, bilateral agencies and country
governments all sign the IHP+ Global Compact. They commit to putting internationally agreed principles for effective aid and development co-operation into practice in
the health sector.
Maternal new
born and child
health platforms
using IHP+
principles1
Efforts to fulfil
human rights
adolescent girls
Every
woman every child
Action for
Adolescent Girls (AAG)
17
Nutrition sensitive approaches for adolescents impact
behavioural outcomes and improve nutrition
Health Education Food chain actors Social Development
• Nutrition counselling
• Micronutrient supplementation
• Sexual and reprod-uctive health ed.
• Contraceptive access
• Compulsory school attendance
• School feeding
• Food fortification
• Diversification of food production
• Improving processing, storage, preservation
• Impr. market access
• Child support grants
• Youth programmes
• Provision of (conditional) food / nutrition support
Sect
ors
B
eha
vio
ura
l ou
tco
mes
Adolescent girl, age 14, food insecure, living in area with high prevalence of HIV and teenage pregnancy
Co
nte
xt
Nu
trse
ns.
po
licie
s
Healthy, well-nourished adolescent girl
Imp
act
18
Nutrition sensitive approaches for adolescents impact
behavioural outcomes and improve nutrition
Health Education Food chain actors Social Development
• Nutrition counselling
• Micronutrient supplementation
• Sexual and reprod-uctive health ed.
• Contraceptive access
• Compulsory school attendance
• School feeding
• Food fortification
• Diversification of food production
• Improving processing, storage, preservation
• Impr. market access
• Child support grants
• Youth programmes
• Provision of (conditional) food / nutrition support
Sect
ors
B
eha
vio
ura
l ou
tco
mes
Sexual behaviours
Uptake of health services
School attendance
Dietary intake
• Delayed sexual debut
• Contraceptive use
• Decreased risk of transactional sex
• ART adherence (if HIV positive)
• Attendance at ante/postnatal care (if pregnant)
• Delayed age of sexual debut
• Engagement in workforce (improved financial prospects)
• Increased dietary diversity
• Consumption of nutrient-rich foods
Adolescent girl, age 14, food insecure, living in area with high prevalence of HIV and teenage pregnancy
Co
nte
xt
Nu
trse
ns.
po
licie
s
Healthy, well-nourished adolescent girl
Imp
act
19
WFP has an important role to play in overcoming global
bottlenecks to improved nutrition outcomes w/ partners
Adolescent girls
Pregnant and lactating
women
Children 6-23 mo
• Meeting micronutrient requirements
• Food support (i.e., school feeding as an enabler for uptake of services)
• Meeting micro nutrient requirements
• Food support in last trimester and first six months of lactation
• Treatment of MAM
• Prevention of undernutrition and stunting
• Difficulty of reaching most at-risk girls (e.g., married, not in school) with nutrition and SRH education
• Programming gap in providing food support to PLWs in food insecure areas
• Lack of access to safe, high quality, nutritious complementary foods to fill the ‘nutrient gap’ for young children
• Governments are reluctant to import good quality comp. foods
• Partnership with UNICEF, UNFPA – adolescent girls and pregnant women
• Nutrition for MNCH in emergencies – PLW, children 6-23 mo
• Increasing access to complementary foods – children 6-23 mo (partnership with CHAI)
Nutrition interventions Global bottlenecks WFP’s contribution
20
SC+, more appropriate from a nutritional perspective, is
not being widely used due to several bottlenecks
Quality & safety of
local products
Perceived Sustainability
Knowledge of
nutrient needs
• Locally produced nutritious foods are often of an inferior quality in terms of nutrient content
• Products can be non adherent to international safety standards
• Lack of knowledge about what constitutes a healthy nutritious diet for children 6-23 months
o Nutrient needs of infant and young children require a diverse diet: breast milk, plant & animal source foods and fortified foods
• High quality products are imported from Europe (Italy and Belgium) and USA
• Governments are hesitant to import SC+ since it is not a sustainable solution for them (in contrast with ARVs?!)
Affordability
• Using natural foods to meet the nutrient requirements can be expensive (buy different fresh foods, avoid spoilage, prepare few times a day)
• Top-end imported complementary foods are costly De
man
d s
ide
bar
rie
rs
Sup
ply
sid
e b
arri
ers
21
SC+, more appropriate from a nutritional perspective, is
not being widely used due to several bottlenecks
Quality & safety of
local products
Perceived Sustainability
Knowledge of
nutrient needs
• Locally produced nutritious foods are often of an inferior quality in terms of nutrient content
• Products can be non adherent to international safety standards
• Lack of knowledge about what constitutes a healthy nutritious diet for children 6-23 months
o Nutrient needs of infant and young children require a diverse diet: breast milk, plant & animal source foods and fortified foods
• High quality products are imported from Europe (Italy and Belgium) and USA
• Governments are hesitant to import SC+ since it is not a sustainable solution for them (in contrast with ARVs?!)
Affordability
• Using natural foods to meet the nutrient requirements can be expensive (buy different fresh foods, avoid spoilage, prepare few times a day)
• Top-end imported complementary foods are costly De
man
d s
ide
bar
rie
rs
Sup
ply
sid
e b
arri
ers
22
Need for developing profitable, sustainable and
innovative business models to scale up nutrition
Partnership
with
Government
• Weak engagement and alignment between private and public sectors
• Weak enforcement of regulation and standards, reducing incentives to invest
• SUN Country strategies inadequately detail the role of business
• Food security and ag national plans and partnerships are well developed but need to address malnutrition
• Importance of partnerships with business acknowledged, but what it means in practice should be outlined
• Costed plans only include public resources
Advocacy
required for
Businesses
• Business is not ‘sensitised’ to its role and impact on nutrition
• Investment in the ‘Bottom of the Pyramid’ not attractive to business (particularly small/medium enterprises)
• Role of business is included for food fortification, agriculture, media, workplace
• WFP’s partnership with CHAI is a good example of a private-public sector business model
Creating
Demand
• Weak evidence for partnerships with businesses
• Institutional demand under-utilised (e.g fortification of food aid, vouchers for nutritious food)
• Models and business cases are growing - evidence base will increase
• Opportunity to incorporate food/nutrition related vouchers in social safety nets
Challenges Opportunities
23
Need for developing profitable, sustainable and
innovative business models to scale up nutrition
Partnership
with
Government
• Weak engagement and alignment between private and public sectors
• Weak enforcement of regulation and standards, reducing incentives to invest
• SUN Country strategies inadequately detail the role of business
• Food security and ag national plans and partnerships are well developed but need to address malnutrition
• Importance of partnerships with business acknowledged, but what it means in practice should be outlined
• Costed plans only include public resources
Advocacy
required for
Businesses
• Business is not ‘sensitised’ to its role and impact on nutrition
• Investment in the ‘Bottom of the Pyramid’ not attractive to business (particularly small/medium enterprises)
• Role of business is included for food fortification, agriculture, media, workplace
• WFP’s partnership with CHAI is a good example of a private-public sector business model
Creating
Demand
• Weak evidence for partnerships with businesses
• Institutional demand under-utilised (e.g fortification of food aid, vouchers for nutritious food)
• Models and business cases are growing - evidence base will increase
• Opportunity to incorporate food/nutrition related vouchers in social safety nets
Challenges Opportunities
24
Business efforts in support of the SUN Movement
WFP and GAIN are co-facilitators of the Business Network
SUN Gov’t
Focal Point
SUN
Country
Network
Civil
Society
Network
Donor
Network
UN System
Network
Business
Network
Countr
y L
evel
Glo
bal Level
SUN
Secretariat
SUN Lead
Group Global platform for business
commitments
• Collective effort of business and various
ways business can support SUN
country plans
• 51 companies have made commitments
– aim for 99 companies by the end of
2015
• Tracking business commitments for the
first time in 2014
Support to SUN Countries
• Developing model for business
engagement (Tanzania, Pakistan,
Nigeria)
• Creating policy guidelines and guides
for engaging business
• 80 companies or business associations
in SUN countries engage in national
plans
Civil
Society
Network
Donor
Network
UN System
Network
Business
Network
Visualization of SUN Business Network What is the SUN Business Network?
25
By reaching 4.1 million beneficiaries in East and Central
Africa, WFP will have a significant impact on malnutrition
WFP will reach 4.1 million beneficiaries by
procuring SC+ with high quality specifications &
standards from Ethiopia and Rwanda
WFP is already reaching 2.8 million beneficiaries
through current programming. However,
• 1.2 million are receiving a less suitable product (SC
instead of SC+)
• 1.6 million are receiving SC+, but for a shorter
duration
WFP will reach an additional 1.3 million
beneficiaries for the prevention of undernutrition
• Country-specific proportion of U2s below poverty
line
Programming will be done in the context of the SUN Movement along with other complementary interventions
WFP’s contribution to 11 SUN countries in East and Central Africa
26
Sustainable, market-based solution to undernutrition in
East and Central Africa
Local production of SC+ entails: Local production of SC+ will prevent
undernutrition and support local economies
• Development of a nutritious product for young children that can be produced locally in Eastern Africa (SC+)
• Engagement with the private sector to invest in the development of factories for SC+ in Rwanda and Ethiopia
• Engagement with smallholder farmers through WFP’s Purchase for Progress (P4P) initiative to procure raw ingredients
Governments of Ethiopia and Rwanda are prioritizing increasing access to good quality comp foods (6-23 mos) use of social safety nets
Preventing undernutrition
• WFP will procure SC+ to support national nutrition programming
• Governments will purchase SC+ to reach vulnerable children through social protection platforms
• Mothers will be able to purchase affordable complementary foods in local markets
Supporting sustainable economic
growth
• Factories will provide guaranteed markets for soya and maize, stabilize prices and help 100,000 smallholder farmers increase income
• Large scale, globally competitive food processing companies will create employment opportunities
27
Sustainable, market-based solution to undernutrition in
East and Central Africa
Local production of SC+ entails: Local production of SC+ will prevent
undernutrition and support local economies
• Development of a nutritious product for young children that can be produced locally in Eastern Africa (SC+)
• Engagement with the private sector to invest in the development of factories for SC+ in Rwanda and Ethiopia
• Engagement with smallholder farmers through WFP’s Purchase for Progress (P4P) initiative to procure raw ingredients
Governments of Ethiopia and Rwanda are prioritizing increasing access to good quality comp foods (6-23 mos) use of social safety nets
Preventing undernutrition
• WFP will procure SC+ to support national nutrition programming
• Governments will purchase SC+ to reach vulnerable children through social protection platforms
• Mothers will be able to purchase affordable complementary foods in local markets
Supporting sustainable economic
growth
• Factories will provide guaranteed markets for soya and maize, stabilize prices and help 100,000 smallholder farmers increase income
• Large scale, globally competitive food processing companies will create employment opportunities
28
Conclusion and recommended actions