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Comprehensive Africa Agriculture Development Programme

(CAADP)

East and Central Africa Regional CAADP Nutrition Program

Development Workshop

Nutrition Country Paper – Rwanda

DRAFT

February 2013

This synthesis has been elaborated in preparation for the CAADP workshop on the integration of nutrition in National Agricultural and Food Security Investment Plan, to be held in Dar-es-Salaam, Tanzania, from the 25th to the 1st March 2013. The purpose of this Nutrition Country Paper is to provide a framework for synthetizing all key data and information required to improve nutrition in participating countries and scale up nutrition in agricultural strategies and programs. It presents key elements on the current nutritional situation as well as the role of nutrition within the country context of food security and agriculture, including strategy, policies and main programs. The NCPs should help country teams to have a shared and up-to-date vision of the current in-country nutritional situation, the main achievements and challenges faced both at operational and policy levels. This work document will be further updated by the country team during the workshop.

http://www.nepad-caadp.net/index.php

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Contents

A. Methodology and Sources of Information ............................................................................................................ 2

B. Context : Food and Nutrition Situation ................................................................................................................. 5

Geography, population & human development ........................................................................................................ 6

Economic Development (Including specific focus on agriculture) ............................................................................. 7

Food Security (food availability, access, utilization, and coping mechanisms) ......................................................... 7

Nutritional Situation .................................................................................................................................................. 8

Infant feeding/Maternal health (DHS 2010) .............................................................................................................. 9

Malnutrition from the perspective of food insecurity ............................................................................................. 11

C. Current strategy and policy framework for improving food security and nutrition ............................................ 13

D. Institutional framework linked to food security and nutrition ............................................................................ 35

Main entities in charge of implementing the food and nutrition policy framework ............................................... 35

Main technical and financial partners ..................................................................................................................... 36

Regional development Partners .......................................................................................................................... 36

National development Partners .......................................................................................................................... 36

UN Agencies ......................................................................................................................................................... 36

Multilateral/bilateral organizations ..................................................................................................................... 36

Local & International NGOs ................................................................................................................................. 37

Coordination Mechanisms ....................................................................................................................................... 38

E. Analysis of current and future country nutritional actions & perspectives......................................................... 39

Institutional framework & funding .......................................................................................................................... 39

Health Sector ....................................................................................................................................................... 39

Agriculture Sector ................................................................................................................................................ 39

Main programmes being implemented to improve nutrition through multi-sectoral approach ............................ 40

F. Analysis in Mainstreaming Nutrition in different sectors, and at the institutional level ..................................... 42

On-going process within nutrition-linked regional and international initiatives ..................................................... 42

Coordination mechanisms and suggestions of improvement ................................................................................. 44

At National level .................................................................................................................................................. 44

At district level ..................................................................................................................................................... 45

Monitoring & Evaluation mechanisms .................................................................................................................... 46

Main Management and Technical Capacities at the Institutional level ................................................................... 46

Main issues at stake to improve the mainstreaming and scaling up of nutrition at the country level and regional/international level ..................................................................................................................................... 47

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A. Methodology and Sources of Information

The paper is prepared by a team of focal points from various government and UN organizations with food security and nutrition mandates. The team initiated the preparation of the draft country profile using primarily secondary data sources (see table 2).

Table 1 : Team Composition Agency Focal Point Position/Designation Contact

MINAGRI Raphael Rurangwa Director General - Planning

MINAGRI Theogene Rutagwenda Director General –Animal Resources

[email protected]

MINAGRI Claude Bizimana CAADP-Focal Point [email protected]

MINAGRI Otto Vianney Muhinda [email protected]

MoH Alphonsine NYIRAHABINEZA/ Leopold Kazungu

Nutrition Expert/ CBNP Officer

[email protected]

MINAGRI Marina Adrianapoli Technical Advisor for Food Security and Nutrition

[email protected]

MINEDUC Claudine Mukagahima [email protected]

MINECOFIN Yvonne Umulisa [email protected]

FAO Dassan Hategekimana Food Security and Nutrition Officer

[email protected]

WHO Dr Maria Mugabo MCH/Nutrition ,Population and Gender Officer

[email protected]

UNICEF Josephine Kayumba Nutrition officer [email protected]

WFP Dr Laetitia Gahimbaza Nutrition, HIV/AIDS and Gender Officer

[email protected]

ONE UN Franklina Mantilla One UN International facilitator-Joint Programming for Nutrition/CADAAP Workshop facilitator

[email protected]

Table 2: Document Sources

Sources Information Web links

FAO

Nutrition Country Profiles http://www.fao.org/ag/agn/nutrition/profiles_by_country_en.stm

FAO Country profiles http://www.fao.org/countries/

FAO STAT country profiles http://faostat.fao.org/site/666/default.aspx

UNICEF Nutrition Country Profiles http://www.childinfo.org/profiles_974.htm

DHS DHS Indicators http://www.measuredhs.com/Where-We-Work/Country-

List.cfm

OMS Nutrition Landscape information system

http://apps.who.int/nutrition/landscape/report.aspx

SUN

Progress Report from countries and their partners in the Movement to Scale Up Nutrition (SUN)

http://www.scalingupnutrition.org/wp-content/uploads/2011/09/compendiurm-of-country-fiches-ROME-VERSION.pdf http://www.scalingupnutrition.org/events/a-year-of-

mailto:[email protected]











http://www.fao.org/ag/agn/nutrition/profiles_by_country_en.stm

http://www.fao.org/ag/agn/nutrition/profiles_by_country_en.stm

http://www.fao.org/countries/

http://faostat.fao.org/site/666/default.aspx

http://www.childinfo.org/profiles_974.htm

http://www.measuredhs.com/Where-We-Work/Country-List.cfm

http://www.measuredhs.com/Where-We-Work/Country-List.cfm

http://apps.who.int/nutrition/landscape/report.aspx

http://www.scalingupnutrition.org/wp-content/uploads/2011/05/110913-SUN-Progress-Report.pdf




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progress/

WFP CFSVA 2012 http://www.wfp.org/food-security/reports/search

MINAGRI Signed Compact / Investment plans / Stocktaking documents / Technical Review reports

http://www.nepad-caadp.net/library-country-status-updates.php

National Agriculture Policy (2004) www.minagri.gov.rw

Strategic Plan for the Transformation of Agriculture

www.minagri.gov.rw

EDPRS Self Assessment Report, Dec 2011

Nutrition Action Plan 2012-2017

MoH National Multi-sectoral Strategy to eliminate malnutrition (2010-2013)

http://www.moh.gov.rw

Joint Action Plan to eliminate Malnutrition (2012)


District plan to eliminate Malnutrition (2011)


Health Sector Strategic Plans II 2009-2012


National Strategy for infant and Young Child Feeding (IYCF) 2011


National Policy on Child Health 2009

Strategic Plan for Acceleration of Child Survival 2008-2012

National Policy on Community Health

National Strategic Plan on HIV and AIDS 2009-2012

National Joint Supervision on District Plan to Eliminate Malnutrition (DPEM) Draft Report, June 2012

JAPEM Assessment: Focused Group Discussion with partners held in Dec 2012

MINALOC National Social Protection Strategy (2011-2016)

www.minaloc.gov.rw

National social protection policy 2005

Implementation Plan for the National Social Protection Strategy (2011-2016)

www.minaloc.gov.rw

MINEDUC Early Childhood Policy 2011

Early Childhood Strategy and Plan 2011-2016

School Health Policy

MINECOFI Vision 2020 (2000-2020) http://www.minecofin.gov.rw


http://www.wfp.org/food-security/reports/search



http://www.minagri.gov.rw/

http://www.minagri.gov.rw/

http://www.moh.gov.rw/





http://www.minaloc.gov.rw/

http://www.minaloc.gov.rw/

http://www.minecofin.gov.rw/

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N

National Economic Development and Poverty Reduction strategy (EDPRS I) 2008-2012

http://www.minecofin.gov.rw

One UN UN Development Assistance Framework for Rwanda (UNDAF) 2013-2017

EDPRS: Lessons Learned 2008-2011

NISR EICV3 2010/11 http://statistics.gov.rw/

http://www.minecofin.gov.rw/

http://statistics.gov.rw/

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B. Context : Food and Nutrition Situation

Table 3 : Key indicators

General Indicators Sources / Year

Population below international poverty line of US$1.25 per day 45% EICV 3 (2010-2011)

Under-five mortality rate (per 1,000 live births) 76% DHSR2010

Infant mortality rate (per 1,000 live births) 50 DHSR2010

Primary cause of under-five deaths

-Respiratory infection

DHSR 2010


Maternal mortality rate /100 000 lively births 487 2010 DHS

Primary school attendance rate 91.7 EICV 3 (2010-2011)

Net attendance rate (males) Net attendance rate (females)

90.7 92.7

Agro-nutrition indicators Sources/Year

Cultivable land area (1000 ha) 1400 MINAGRI SPTAII (2009)

Access to improved drinking water in rural areas 74.2% EICV3 (2010-2011)

Access to improved sanitation in rural areas 74.5% EICV3 (2010-2011)

Food Availability

Average dietary energy requirement (ADER) 2100 kcal Report,MoA 2012

Dietary energy supply (DES) 2,938 kcal Report,MoA 2012


Total protein share in DES 118% Report,MoA 2012

Fat share in DES 60% Report,MoA 2012

Food Consumption

Average daily consumption of calories per person 2,938 Report,MoA 2012

Calories from protein na

Calories from fat na

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Agro-nutrition indicators (continued) Sources/Year

Nutritional Anthropometry (WHO Child Growth Standards)

Prevalence of stunting in children < 5 years of age 44% DHS (2010)

Prevalence of wasting in children < 5 years of age 3% DHS (2010)

Prevalence of underweight children < 5 years of age 11% DHS (2010)

% Women (15-49 years) with a BMI < 18.5 kg/m² 7.3% DHS (2010)

% Women (15-49 years) with a BMI >25 kg/m² 16.3% DHS (2010)

Infant feeding by age

Children (0-6 months) who are exclusively breastfed 85% RDHS 2010)

Children (6-8 months) who are breastfed with complementary food 62% DHS (2010)

Children (9-11 months) who are using a bottle with a nipple 6.6% DHS (2010)

Children (20-23 months) who are still breastfeeding 83.5 % % DHS (2010)

Coverage rates for micronutrient supplements

% Households consuming adequately iodized salt (> 15ppm) 99% DHS (2010))

Vitamin A supplementation coverage rate (6-59 months) 92.9% DHS (2010)

Vitamin A supplementation coverage rate (<2 months postpartum) 52.2% DHS (2010)

Prevalence of anemia among pre-school children 38% DHS (2010)

Prevalence of anemia among pregnant women 19.5% DHS (2010)

Geography, population & human development

1. Rwanda is a landlocked country situated in Central Africa, bordered to the North by Uganda, to the East by Tanzania, to the South by Burundi and to the West by the Democratic Republic of Congo. Considered to be among the smallest countries on the continent, Rwanda’s total area is estimated to be 26,338 KM2 According to Rwanda’s National Institute of Statistics (NISR), in 2011, the population density in Rwanda was estimated to be 4161 people per KM2 and the total population is approximately 10.8

million.- The population of Rwanda is young with 43% < 15 years old. Moreover, women account for

about 52.6 % of the population.-

2. Rwanda ranks 166 out of 187 countries on the UNDP’s HDI (UNDP HDI 2011) and is in the category of Countries with a low Human Development Index (HDI). With an HDI of 0.429, the country is below the regional average of 0.463. The vast majority of the population depends on agriculture for their livelihoods. Recent surveys indicated that the percentage of people living under poverty has dropped by almost 12% from 56.7% in 2006 to 44.9% in 20112.

3. With its Vision 2020 objective of combating poverty, the Government of Rwanda ihas embarked on a comprehensive program of privatization and liberalization with a goal of attaining rapid and sustainable economic growth. The goal is to transform the economy from its 90% dependence on subsistence agriculture into a modern, broadly based economic engine, welcoming investors and creating employment and new opportunities. Rwanda's recent entry into the East African Community (an economic bloc comprising Uganda, Kenya, Tanzania and Burundi) should improve its international standing.

1 Provisional results 2012 Rwanda Population and Housing Census

2 EICV3 2010/11

http://statistics.gov.rw/

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4. The Governments Vision 2020 has done much to streamline development initiatives and contribute to economic and social growth. Education has become 18% of public expenditure for the continuous committed improvement of the quality and access to education. During his 2010 presidential campaign, President Paul Kagame announced free twelve year basic education. Health coverage has now exceeded 90% and over 80% of HIV/AIDS infected Rwandans are receiving treatment. Maternal and child mortality rates from 750 to 487 deaths per 100,000 live births 2005 to 2010 have dramatically decreased from 152 to 76 under five children deaths per 1,000 live births respectively. The country’s commitment to the environment is exemplary. It is the only country in Africa where plastic bags are banned. Its capital, Kigali, and other towns in Rwanda are among the cleanest on the continent.

Economic Development (Including specific focus on agriculture)

5. The Government of Rwanda gives high priority to achieving sustainable economic growth for all as a mean to meet the targets set by the MDGs. In 2011, the contribution of the agricultural sector to poverty reduction was of paramount importance in Rwanda, not only through increased food availability but also through the creation of employment opportunities and the implementation of risk-mitigation infrastructures for irrigation and land husbandry. In addition, non- agricultural activities and business climate also registered significant improvements in 2011, as evidenced by the Composite Indicator of Economic Activities. In 2011, Rwanda’s economy continued to grow with a real GDP growth expected to reach 8.8% for the year compared to 7.5% in 2010. This is mainly driven by the performance in the agricultural and industrial sector- strong harvest, robust exports and ample domestic demand3. By 2011, Rwanda’s total export value has dramatically increased from 27% in 2010 to 56%. Coffee, tea, minerals are the leading export products4. Narrowing the high levels of income inequality is a major challenge to poverty reduction in the country.

Food Security (food availability, access, utilization, and coping mechanisms)5

6. Rural livelihoods are based on agriculture. Small family farms of less than 1 hectare are the norm. Farmers practice mixed farming that combines rain fed root and tuber crops (sweet potatoes, cassava and Irish potatoes), cereals (maize and sorghum) dry beans, plantain, banana and traditional livestock-rearing and some vegetable production. About 71% for all crops produced are consumed and only 23% are sold on the market. Crops that households kept mostly for consumption were the main consumed cereals, roots and tubers as well as beans, and cooking banana. Apart from crops grown, 70% of all househols in rwanda own some type of livestock. Animal products are good source of proteins and lipids and in times of crisis livestock as shock absorber, contributing to the resilience of poor households. Food availability does not seem to be the problem. Food production is increasing, markets are functioning relatively well and food is flowing easily within and outside the country due mainly to well connected road network and market infrastructure.

7. Although 85% of households cultivate land and rely on agriculture or livestocks as the main(and often) and only livelihood activity, for many of this households, access to productive land is a problem, which has implication on household food consumption score: the smaller the cultivated plot the more likely they are to have low food consumption score. About 60% of farming households cultivate plots smaller than .5 ha often in steep slopes coupled with poor soil fertility. Households reporting some type

3 One UN Rwanda Annual report 2011

4 Rwanda Exports 1998-2011

5 CFSVA 2012

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of difficulty in accessing food in 2011-2012 consitute about 50% of the total households in Rwanda, of which 21% are classified as food insecure having unacceptable food consumption before the harvest season. These food insecure households are typically poor rural households, living in crowded homes, relying on low income agriculture and casual labour. They farm small plots of less than 0.5 ha often in steep slopes with infertile soil. They have limited education and are often illiterate. They are often headed by an elderly person and or by a woman/widow.

8. The causes of food insecurity and malnutrition in Rwanda is mainly poverty, high reliance in agriculture and undiversified livelihoods. The fewer crops a household cultivated during the first season, the more likely it is to be food insecure. Difficult access to food markets and the lower level of education of the household head are also identified as major contributors to food insecurity and malnutrition. To a certain extent, food insecurity is addressed by food aid and household coping strategies.

9. The overall numbers of calories available for consumption in Rwanda has increased over the past 10 years. Sustained growth in the agricultural sector will help close the gap between availability and demand, both in terms of increasing rural incomes to purchase foodstuffs as well as increasing production for home consumption.

Nutritional Situation

10. There have been improvements in nutritional status of children under five years in the past 10 years. The percentage of stunted children fell from 51% in 2005 to 44% in 2010. Decreasing trends have also been observed in both wasting and underweight, from 5% to 3% and 18% to 11% respectively. Although the levels of acute malnutrition (wasting) are relatively low (acceptable level), the levels of chronic malnutrition for children under 5 remains alarming.

11. Children who are short for their age are those who have not received adequate nourishment over a long period due to food shortages or chronic or recurrent illness. In Rwanda, 44.2% of children under 5 years of age are stunted (DHS 2010). Male children are more stunted than females; respectively 47.4% and 41.1%. It has also observed a big difference in rates of stunting between regions: Kigali city with 27.3% compared to 46.5% in North province. Almost twice as many children from the lowest wealth quintile (55%) are stunted compared to those from the highest wealth quintile (30%).

Figure 1: Stunting Trends: % of childern <5 years of age stunted (NCHS Reference Population)

Source: RDHS 2010

44 51 45 43 42

48

0

10

20

30

40

50

60

1990 2000 2010 2020

2006 WHOChild Growthstandard

US Nat'l Centerfor HealthStatistics(NCHS)

Figure 2: Under Weight Trends: % of children <5years of age underweight

Source: RDHS 2010

11

18

23 27

29

0

5

10

15

20

25

30

35

1990 2000 2010 2020

2006 WHO ChildGrowth standard

US Nat'l Centerfor HealthStatistics (NCHS)

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12. Wasting rates, which show nutritional status at the time of survey, were at 2.8% (DHS 2010) for children 5-59 months, with children falling in 9-11 month age groups showing the highest rates 3.8%. Wasting peaks at 12- 23 months and could indicate less than adequate feeding practices.

13. These improvements in the nutritional status of Rwanda children are attributed to the National Plan to Eliminate Malnutrition, which includes active nutrition screening of children by community health workers. Children who are at risk of malnourishment have been systematically referred to health facilities for appropriate treatment such as therapeutic milk, and ready to use therapeutic food for severe cases, and corn soy-blend for moderate cases. Other sustainable approaches have also been initiated and inlcude infant and young child feeding, community based nutrition programs and behaviour change communicationand home food fortification.

14. The CFSVA and nutrition Survey 2012 identified the following causes of stunting in childern under 5 years as follows: (1) intergenerational cycle of chronic malnutrition (young mothers who are stunted themselves are likely to have stunted children; (2) education (mothers who have not completed secondary education are likely to have stunted children): (3) individual factors ( low birth weight: the smaller the baby was at birth, the more likely it is to be stunted). In Rwanda, boys are more stunted than girls; and (4) child food consumption patterns (children aged between one and two years, who had consumed yogurt or milk, were significantly less likely to be stunted than other children in the same category).

Infant feeding/Maternal health (DHS 2010)

15. Close to 10% of women aged 15-49 years old who are not pregnant or who have not given birth in the past two months are considered thin (body mass index, BMI< 18.5 kg/m2). Obesity is a risk factor for numerous diseases and 16.3% of women are overweight/obese. Overweight is a bigger concern for women in the richest quintile and those with a secondary or higher education (both at 23%).

16. Optimal Infant and child feeding practices are crucial to determining children’s nutritional status. Nearly all children, 98%, are breastfed for some period of time and of those 68% began breastfeeding within one hour of birth (early initiation IE) and 92% began within one day of birth. At 6 months, infants need more nutrients than breast milk can provide. WHO recommends a variety of solid and semisolid foods to be gradually introduced into a child’s diet with a minimum frequency depending on the age of the child and the amount of breast milk they consume. In Rwanda, 37% of children age 6-23 months met the minimum standard with respect to frequency and diversity. Women of childbearing years need to be in good health and have adequate care to ensure good outcomes for their children. Most women (96%)

Figure 3: Stunting prevalence by gender, residence and Wealth status

Indicator

(WHO

Standards)

DHS (2010)

Gender

Residence

Wealth quintile

Male Female Ratio

m/f

Urban Rural Ratio

u/r

1

Poor

2 3 4 5

Rich

Ratio

r/p

Stunting

prevalence

52 49 1.1 37 53 0.7 60 54 52 51 35 0.6

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received antenatal care from trained health personnel with very little differences between regions or income levels. Approximately 45% of women delivered in a health facility and 52% were assisted by a trained health care provider.

17. Although the prevalence of anemia has also dropped 16 percentage points in the past 5 years, from 56% to 38%, it remains a critical public health problem in Rwanda. Anemia is common among children in Rwanda and nearly two in five (38%) children 6 – 59 months of age are anemic. Of real concern is that 70% of children 6-8 months of age are anemic. The East province has the highest overall rates with 43% of children anemic and rural children have a slightly higher rate of anemia than do urban children. Rwanda, through campaigns and twice-yearly Mother and Child Week events has been providing vitamin A supplementation and deworming to children age 6-59 months. Vitamin A supplementation reaches 93% of children 5 years or less. The DHS also found that 88 % of households were using adequately iodized salt.

18. The overall prevalence of anemia among women has also decreased by 8 percentage points since 2005 RDHS. This downward trend went further down from 2005 to 2010; the proportion of mildly anemic women deceased from 19% in 2005 to 14% in 2010 while moderate anemia has also declined by half. Anemia is present in only 17% of women between 15-49 years of age. Anemia is more prevalent among women who are of high parity (more than 4 children), have no education,are pregnant, and live in poor households. Prevalence of anemia does not vary significantly between the rural and urban areas. Regional differences show however that the prevalence is higher in the East province (23%) than in the Nortn province (12% ).

19. Infant Mortality. The main causes of under 5 mortality in Afrcican region is presented in the figure below. 1.2. million babies di for the first month. Almost a million die from pneumonia, and 720,000 form diarrhoea and 690,000 million from Malaria. In Rwanda, one of the main causes of infant mortality is respiratory infection (RDHS2010).

Source: WHO World Health Statistics 2009

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Malnutrition from the perspective of food insecurity

Figure 4: Distribution of Stunting by Province Source: Rwanda DHS 2010

Figure 5: Stunting Rates by Districts Source: CFSVA 2012

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Figure 6: Level of food insecurity by Livelihood Zones

Figure 7: Level of Food insecurity by Districts Source: CFSVA 2012

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C. Current strategy and policy framework for improving food security and nutrition

Table 4: Compendium of policies and strategies relevant to food security and nutrition

Strategy / Policy Reference

Period Objectives and main components Budget / Donor Lead Agency Key points

Integration of Nutrition

STRATEGIC FRAMEWORK

Vision 2020 2000-2020 Seeks to fundamentally transform Rwanda into a middle-income country by the year 2020. This will require achieving annual per capita income of US$ 1240 (US$ 540 as of 2010), a poverty rate of 30% (44.9% as of 2010) and an average life expectancy of 55 years (54. 5 years as of 2010). Six Pillars :

Good governance and a capable state

Human resource development and a knowledge based economy

A private sector-led economy

Infrastructure development

Productive and Market Oriented Agriculture

Regional and International Economic integration.

Ministry of of Finance and Economic Planning (MINECOFIN)

Promotion of macroeconomic stability and wealth creation to reduce aid dependency Transforming from an agrarian to a knowledge-based economy Creating a productive middle class and fostering entrepreneurship Nutrition issues are scattered throughout the documents in one way or another through Health sector . EDPRS 1 as the medium term implementation strategic plan of vision 2020 so that all elements emphasizing on nutrition issues in EDPRS 1 reflect everything that is related to nutrition in Vision 2020 includes reduction of child malnutrition Key indicators Details of interventions are defined in

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National Economic Development and Poverty Reduction strategy (EDPRS I)

2008-2012 Defines the overall agricultural sector goal: to achieve sustainable economic growth and social development, leading to the increase and diversification of household incomes, and ensuring food and nutrition security for the entire population. Policy actions are formed around three clusters: economic, social and governance.

The economic cluster covers macroeconomic management, sectoral development with an emphasis on agriculture, infrastructure, private sector development, climate change and natural resources.

The social cluster focuses on improvements in the state of education, health, social protection and access to clean water.

The governance cluster covers performance indicators on public financial management, justice, reconciliation law and order.

Strategic actions are further defined in EDPRS II (currently being finalized). EDPRS II Main goal is to ensure a better quality of life for all Rwandans through rapid economic growth and poverty reduction.

RWF 5,151 billion

MINECOFIN For health, the EDPRS aims to maximise preventive health measures and build the capacity for high quality and accessible health care services for the entire population in order to reduce malnutrition, infant and child mortality, and fertility, as well as to control communicable diseases.

Situation analysis includes the issue of child malnutrition and stunting;

Nutrition is included in the targets under "Improve health status and slow down population growth" - reduce the incidence of chronic malnutrition (stunting) among the under-fives from 45% to 35% and decrease the prevalence of anaemia among women aged 15- 49 from 33% to 20%;

Nutrition relevant sectoral interventions to achieve targets (underHealth sector) includes: (a) increase geographical accessibility to quality health care services - to provide a comprehensive preventative and care package including nutrition; (b) decrease the prevalence of childhood diseases through IMNCI; (c) Reduce the rate of chronic and acute macronutrient

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malnutrition and the prevalence of micronutrient deficiencies; and (d) (establishment of a Nutrition Surveillance System as part of a comprehensive Food Security and Early Warning System

Cost for nutrition is allocated under the sector Health and population

On going priorities from EDPRS I that is being continued in EDPRS II concerns foundational issues, which include addressing malnutrition

UN Development Assistance Framework for Rwanda (UNDAF)

2013-2017 Five results Areas: 1 .Good governance enhanced and sustained; 2. Health, Population, HIV and Nutrition: The maternal morbidity and mortality, the incidence and impact of HIV and AIDS and other major epidemics, and the rate of growth of the population are reduced; 3. All children in Rwanda acquire a quality basic education and skills for a knowledge-based economy; 4. Management of the environment, natural resources and land is improved in a sustainable way; 5. Sustainable Growth and Social Protection: the Rwandan Population benefits from economic growth and is less vulnerable to social and economic shocks. Main Areas of Actions(components):

Rule of law, Access to

Funding source indicated in the COD key activities matrix - a Joint Programme and will be funded by a combination of existing core and non core resources of participating organizations and the ‘One UN Fund for Rwanda’

United Nations System in Rwanda

Presents as a common business plan for the United Nations agencies and national partners, aligned to the priorities of the host country and the internationally agreed development goals. Aims to bring together agency specific planning requirements in a consistent and seamless manner, and ensure a ‘necessary and sufficient’ programme logic in the results chain and resource requirements. Nutrition is a core element under UDAF Result 2 with outcomes as follows:

Outcome B1 Effective health System Quality, effectiveness

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Justice & Peace consolidation

Evidence based policy making & accountability

Decentralization & Participation

Gender equality

Response to HIV

Health, Population, Nutrition

Enrolment & Retention

Achievement (basic quality education for all children)

Effective education system

effective system for the management of a sustainable environment

Ecosystems Restoration & protection

Sustainable use of natural resources

Sustainable Economic Growth

Social Protection & Vulnerability Reduction

and efficiency of the health system, including Nutrition, Reproductive Health, Maternal & Child health and Family Planning services improved Resources

Outcome B2. Health practices

Health care, nutrition, and hygiene practices at family and community level improved

Outcome B3. Disease control and epidemic prevention

Prevention and response to communicable and non communicable diseases and major epidemics improved

All activities are costed.

NUTRITION SPECIFIC POLICIES/STRATEGIES/PLANS

National Nutrition Policy

2007

General objective: to improve the nutritional status of the Rwandan people, prevent and appropriately manage cases of malnutrition. Specific objectives: Promote practices favorable to the improvement of the nutritional status: 1. Reduce the prevalence of diseases linked to

nutritional deficiencies and excesses, 2. Assure adequate treatment and prevention of

malnutrition due to nutritional deficiencies and excesses,

3. Prevent mother-to-child transmission of HIV through appropriate breastfeeding and infant and young child feeding practices,

4. Provide appropriate nutritional support and

No budget indicated, but financing mechanisms is defined

Ministry of Health

Key strategies include addressing malnutrition: 1. Reinforcement of the political

commitment 2. Promotion of optimal infant and

young child feeding 3. Scaling up of community-based

nutrition programs 4. Food Fortification 5. Promotion of household food

security 6. Prevention and management of

nutritional deficiency or excess-related diseases

7. Nutritional support and care to

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care for people living with HIV/AIDS PLWHA and their families 8. Promotion of pre-school and

school nutrition 9. Communication for behavior

change

Specific interventions and costing are reflected in the NSEM

Multisectoral Strategy (and action plan) to Eliminate Malnutrition (NSEM)

2010-2013 General Objective: To improve the nutrition status of the vulnerable populations (children under five years, pregnant and lactating mothers and school going children) in Rwanda in order to reduce morbidity and mortality related to malnutrition through a multi-sectoral approach. Impact objective: Reduce by 30% all forms of malnutrition in Rwanda by 2013

Ministry of Health

Strategies: 1. Identification and management

of under nutrition 2. Scale-up community-based

nutritioninterventions (CBNP 3. Elimination of micronutrient

deficiencies 4. Multi-sectoral District Plans to

Eliminate Malnutrition (DPEMs) 5. Prevention and management of

nutritional deficiencies and excess-related diseases

6. Behaviour Change Communication

7. Coordination of Nutrition Partners

8. Monitoring and Evaluation for Nutrition activities at all levels

The strategy includes and action plan for implementation which is costed.

District Action Plans to Eliminate Malnutrition (DPEMs)

2011 Impact objective: Reduction in malnutrition through implementation of DPEM activities Expected results

100% of districts have developed plans/imihigo to eliminate malnutrition through multi-sectoral approach

18,250,000 Rwf Mainly from District budget Plus

Districts DPEM incorporates positive aspects of community-based nutrition programmes and existing interventions that aim to protect the nutrition of young children and pregnant and

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100% of districts implement their plans/imihigo to eliminate malnutrition at the community level.

Additional support from UN, bilateral/multi-lateral organizations, NGOs and Ministries

lactating women.

DPEM incorporates linkage with programmes to improve water and sanitation, enhance agricultural production and food security, school gardens, prevent and manage HIV/AIDS and social protection systems for vulnerable groups

Plans are costed

Joint Action Plan to Fight Malnutrition (JAPEM)

2012 General Objective: To improve the nutrition status of the vulnerable populations (children under five years, pregnant and lactating mothers and school going children) in Rwanda in order to reduce morbidity and mortality related to malnutrition through a multi-sect oral approach. Impact objective: Reduce by 30% all chronic and acute form of malnutrition in Rwanda by 2012. Specific Objectives 1. Reduce malnutrition in children aged between 6 - 59 months (moderate by 35%, acute by 10% and thinness among pregnant and lactating mothers ( 3%) by effectively managing cases of under nutrition by 2012; 2. Reach 80% of the population with effective mechanisms that prevent under nutrition through community based nutrition interventions by 2012; 3. Reduce micronutrient deficiencies by 20% among children under the age of five years and pregnant and lactating mothers by 2012; 4. Provide optimal nutritional care and support 80% of children under the age of five years and pregnant & lactating mothers by 2012;

6,237,648,480 RwF (not including staff time cost)

Prime Minister Office Ministry of Health Ministry of Gender and Promotions of Family Affairs Ministry of Agriculture Ministry of Local Government Ministry of Education

Four strategic interventions: 1. District plans to eliminate

malnutrition (DPEMS) 2. Behaviour change

communication 3. Coordination of all

implementation plans 4. Monitoring and Evaluation

Plan is costed.

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5. Reach 90% of the population with Behaviour Change Communication messages in improvement of nutrition (under-nutrition and over nutrition) by 2012; 6. Set-up a mechanism for monitoring and evaluation of the nutrition interventions.

NUTRITION SENSITVE POLICIES/STRATEGIES/PLANS

Agriculture

Comprehensive Africa Agricultural Development Programme (CAADP)

2007 Main goal: to help African countries reach a higher path of economic growth through agriculturally-led development which eliminates hunger, reduces poverty and food and nutrition insecurity, and enables expansion of exports.

The focus of the CAADP process is to strengthen and add value to the Strategic Plan for Agricultural Transformation (PSTA) under the ongoing Economic Development and Poverty Reduction Strategy (EDPRS).

In Section 3.3 of its National Aid Policy, the Government of Rwanda (GoR) stresses the essential nature of strong strategic plans in all sectors and calls for the improvement of existing policies and strategic plans.

10% of National Budget

Ministry of Agriculture

Strategies

Helping define a coherent long term framework to guide the planning and implementation of current and future EDPS/PSSTA programs under the Vision 2020 agenda;

Identifying 2 strategic options and sources of poverty reducing growth for the agricultural sector between now and 2020; and

Developing existing and new strategy analysis and knowledge support systems to facilitate peer review, dialogue, and evidence based planning and implementation of agricultural sector policies and strategies.

The compact sets out Government’s agenda for Agricultural Growth, Poverty Reduction, and Food Nutrition Security. The CAADP compact is based on

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PSTA II (ended in 2012): The government of Rwanda confirms its commitment to promoting long term economic and social development to reduce poverty and achieve food and nutrition security

Agricultural Sector Investment Plan

2009-2012 Purpose: to contribute to sustainable food and nutritional security, icnrease income of households, and to secure national economic growth. Four strategic programmes: 1. Agriculture and animal resource intensification 2. Research, technology transfer and

professionalisation 3. Value chain development and private sector

investment 4. Institutional development and agricultural

cross-cutting issues

502,206,359 USD (with 41% investment gap)


Achieving food and nutrition security for all Rwandans and halving poverty is one of the absolute priorities of the government.

This will be achieved by increasing the productivity per hectare of staple crops (under Programme 1)

Specific interventions addressing malnutrition is embeded in the PSTA II strategic documents.

Securing nutrition security is costed under Programme 1

One specific nutrition programme (under sub-programme 1.2) is the “One Cow per Household” – to distribute 270,000 cattles over four years

National Agricultural Policy

2004 Global objective: To create conditions favourable to sustainable development and promotion of agricultural and livestock produces, in order to ensure national food security, integration of agriculture and livestock in a market-oriented economy and to generate increasing incomes to the producers. Strategies: 1. Strengthening research and extension


Problem analysis includes nitrition situation: Access to food is hindered by the prevailing poverty in the country, which result primarily in food and nutrition insecurity

Nutritional aspects a criteria for selection of priority commodities

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2. Intensification 3. Agricultural marketing 4. Diversification and regional specialisation 5. Diversification and regional specialisation 6. Intensification and integration of

agriculture/livestock 7. Commodity-based approach and regional

specialisation 8. Diversification 9. Marketing of animal products 10. Marshlands management 11. Water conservation and soil fertility

management 12. Integration of erosion control and soil

management in the technological package to extend to the farmer

13. Agricultural mechanisation Land law and land reform

Small cattle programme for farmers to take into account ecomonomic and nutrition impact of small cattle at family level

Strategic Plan for the Transformation of Agriculture (PSTA II)

2008-2012 The Overall Objective of the PSTA II is: “Agricultural output and incomes increased rapidly under sustainable production systems and for all groups of farmers, and food security ensured for all the population”. The Specific Objective is to: “Increase output of all types of agricultural products with emphasis on export products, which have high potential and create large amounts of rural employment; this under sustainable modes of production”. Four strategic programmes: 1. Intensification and development of

sustainable production systems 2. Support to the professionalization of

producers 3. Promotion of commodity chains and

103 Million USD (general and annual PIP provision)

And an additional 139.4 Million USD (non- disbursed resources for projects in the agricultural sector)


1. Intensification and development of sustainable production systems: (i) sustainable management of natural resources and water and soil conservation (ii) integrated livestock systems; (iii) marshland development; (iv) irrigation; (v) supply and use of agricultural inputs; (vi) food security and vulnerability management. 2. Support to the professionalisation of the producers: (i) the promotion of rural organizations and the reinforcement of producers’ capacities; (ii) restructuring of proximity services to producers; (iii) rural innovation and research for development; (iv) rural

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agribusiness development 4. Institutional development

PSTA III (2013/17) is currently being finalized with nutrition as a sub-programme.

financial systems and agricultural credit development. 3. Promotion of commodity chains and agribusiness development: (i) creation of a conducive business environment and promotion of entrepreneurship; (ii) commodity chains promotion and development; (iii) processing of agricultural products and competitiveness; (iv) rural support infrastructures. 4. Institutional development: i) legal and regulatory framework reform; (ii) public services reform and institutional support; (iii) coordination and evaluation of the agricultural sector SPTA 2 has limited references to the direct/indirect and positive/negative effects of the agricultural sector over health and nutrition

6

Nutrition Action Plan (Final Draft for approval)

2012-2017 Main Objective: to improve the nutritional status of the vulnerable population in Rwanda in order to reduce morbidity and mortality related to malnutrition through a multi-sectoral approach. Specific objectives:

Improve household access to agricultural

Budget under preparation


The MINAGRI Nutrition Action

Plan 2012-17 (NAP 2012-17)

incorporates food and

agricultural based interventions

with explicit nutrition objectives

and indicators, aiming at

6 Situation Analysis, Draft Nutrition Action Plan 2012-2017, MINAGRI

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resources and technology

Diversified food production and consumption

is promoted at the HH level

Increase food accessibility for the most

nutrition insecure households

Improve food access during the lean season

period

Sustain food markets

Improve food and nutrition security

governance

Key Interventions:

GIRINKA and small livestock

Soil Erosion Protection

Small scale irrigation

Integrated Kitchen Garden Package

Diversified food production and consumption

Behaviour Change Communication to promote

intra-household distribution

Income Generating activities

Social Transfers schemes

Optimized Food Harvesting, Storage and

Processing

Early Warning System

addressing food insecurity and

malnutrition in Rwanda, to

achieve the MDG targeted

objective of less than 24.5% of

chronic malnutrition prevalence

by 2015 (EDPRS).

The focus is on food insecure

rural households, female-

headed households, poor

farmers and small-holders.

Chronic malnutrition has been

adopted as one of the main

criteria of prioritization,

therefore vulnerable groups

such as infants and young

children, as well as women in

reproductive age, have been

targeted

Priority has been given to

districts with high prevalence of

stunting and anaemia, as well as

drought-prone areas.

A gender-responsive approach

has been adopted throughout

the formulation of the plan to

ensure the achievement of

program or policy goals.

The plan has not been budgeted

yet (but underway)

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Public Health

Health Sector Strategic Plans II

2009-2012 Three strategic Objectives 1. to improve the accessibility to, quality of and

demand for FP/MCH/RH/Nutrition services 2. to consolidate, expand and improve services

for the prevention of disease and promotion of health

3. to consolidate, expand and improve services for the treatment and control of disease

Seven Strategic Programmes 1. Institutional capacity 2. Human resources for health 3. Financial accessibility 4. Geographical accessibility 5. Drugs, vaccines and consumables 6. Quality assurance 7. Specialised Services, National Referral Hospitals and Research capacity

1,445.2 million USD (total resource requirement)

Ministry of Health

Nutrition is among 3 strategic objectives of HSSPII

Nutrition have been separated into their own objective. This is to illustrate their critical importance to the health sector for the next three years as they contain many indicators related to MDGs and priority areas in the EDPRS.

Strategic interventions nutrition include: (a) Expand integrated community health care package (ICHP) to all 30 districts; (b) Strengthen Integrated management of neonatal and childhood illnesses in all health facilities; (c) Continued expansion of immunization services including pneumococcal and rotavirus; (d) Promotion of exclusive breast-feeding for 0-6 months; (e) Promote good nutrition practices, including under fives, school children, pregnant women and breastfeeding mothers; (f) Problem analysis includes malnutrition situation

HSSP III, which is currently under development, indicates key indicators on MCH nutrition: (a) children in nutrition

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rehabilitation programmes; (b) children U5 screened in CBNP; (c) Wasting prevalenc of U5 childeren e; (d) stunting prevalence of under 5; (e) Underweight prevalence of under 5

Implementing strategies with action plan and costing are defined in the NSEM,

National Strategy for infant and Young Child Feeding (IYCF)

2011 Main objective: Through optimal infant feeding- the nutritional status, growth of infant and young children to reduce morbidity and mortality to ensure their survival, growth and development. Specific objectives 1. Improve optimal practices of exclusive breast

feeding during the six first months. 2. Encourage breastfeeding within the first hour

after delivery. 3. Create adequate sitting rooms/ breastfeeding

rooms in all work places for nursing mothers to breastfeed their babies or express their breast milk.

4. Improve and facilitate access to complementary feeding from the first 6 months.

5. Support breast feeding at least until the age of two years.

6. Promote the production and consumption of foods fortified in micronutrients.

7. Strengthen the collaboration with international organizations and sectors interested in engaging the government in

Costing of interventions not yet done (but is underway)

Ministry of Health

Main Interventions:

Promoting appropriate feeding for infants and young children in Rwanda: - Breastfeeeding 0-6 months - Complimentary Feeding 6-

24 months - Feeeding practices and

nutritional support for children minus 9 months (pregnant women)

IYCF in difficult circumstances

Implementing high priority interventions to improve IYCF practices

M&E

:

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favor of optimal feeding practices for infants and young child.

8. Run a follow up and evaluation system of IYCF at FOSA and community level starting now to 2012.

9. Provide orphans and other vulnerable infants with access to services of infants and young child feeding.

10. Implement a plan of preparing and coming up with solutions to crisis situations.

National Policy on Child Health

2009 The Policies of health of the child consist the essential rights and the important interventions in the domain of health for the age groups of 0 to 9 years. Main objective: to decree the important and indispensable hygienic interventions, applicable in Rwanda in the context of the moment and permitting to guarantee the survival, the development and the blossoming of the child. Suitable interventions outlined (at different stages of the life cycle): 1. Before conceptionperiod 2. The conception period 3. The newborn period 4. The post childbirth period 5. The childhood, and the young child child

period before schooling 6. The integrated handling of child’s illnesses 7. The peiod of school 8. HIV infection 9. Social Welfare of the child 10. Behaviour Change Communication

Ministry of Health

It is accompanied by a strategic plan of acceleration of the child's survival

Problem analysis features malnutrition: The improvement of the nutritional statute and the state of health of the mothers and the provision of health care of the quality reproduction are the pivot to tackle the numerous underlying reasons of the mortality of the children.

Nutrition specific policy inetrevntions: - The prevention of malnutrition is amongs the interventions included under focused cares, BCC, post natal cares (nutrition counseling), child survey - The services of health of the child and the communal services will assure the surveillance of the nutritional state of the children, the prevention and the

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handling of the nutritional deficiencies by the promotion of a balanced food preferably based to local products. -The prevention of the specific nutritional deficiencies (iron, iodine, vit. A) - All children suffering of malnutrition must benefit from a tracking HIV; and all children tested positive must be referred to the nearest ARV service

Strategic Plan for Acceleration of Child Survival

2008-2012 Strategic goal: To contribute to the improvement of the under five-year olds state of health in order to move fast towards MDGs and the Rwandan 2020 vision. Specific Objectives: - To reduce the under five-year olds mortality from 103%° in 2007 to 50%° in 2012 -To reduce neonatal mortality from 28%° in 2007 to 15%° in 2012 -To reduce infantile mortality from 62%° in 2007 to 30%° in 2012 Five strategies to reach these goals: 1. Improving availability and accessibility / Extending integrated package coverage of interventions with high quality impact for the mother, the newborn and the child healthcare. 2. The increase of demand and the use of the services to maximize the impact of implemented interventions with an emphasis on communication for the reduction of the socio-cultural barriers for the change of behavior for the benefit of the mothers and children survival.

During phase I (2008-2009): 5, 603,200 USD ( based on 800 USD (estimated cost per saved life) During Phase II (2010-2012): 42, 762,720 USD (based on 1,560 USD per saved life)

Ministry of Health

Problem analysis features malnutrition (featured as a separate section to emphasize its importance)

Specific intervention features fighting malnutrition: Special efforts must be made for the fight against malnutrition to reach the objectives of mortality reduction

These set of actions are outlined in the NSEM

Preventing malnutrition is featured in the Phases, targets and mode of service supplies

Nutrition specific actions are featured in the implementation plan and in the provisional budget for 2008-2012

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3. The creation of institutional and economic environment suitable for the passage to the scale of the package of interventions to high impact through the human resource capacity building and setting up the sustainable healthcare financing system for the mother, the newborn and the child. 4. The efficient Coordination and implementation of this strategy that include the reinforcement of collaborative mechanisms between different programs in favor of the mother, the newborn and the child, the large- scale advocacy and the decentralized planning system. 5. The follow-up and evaluation of the strategy using relevant indicators of monitoring and taking decisions based on facts. Main interventions are delivered according to 3 modes od care and in 3 phases: 1. Providing family/community-based care 2. Providing population-based care 3. The clinical individual care

National Policy on Community Health

General objective: to provide clear guidance for the provision of holistic and sustainable health care services to communities with their full participation. Community health programme components:

Integrated Management of Childhood Illnesses (C-IMCI)

Community Maternal and Newborn Health (CMNH)

Community based provision of family planning (CBP)

Community-based Nutrition Program (CNP)

Community based Environmental Health Program (CBEHP)

The Ministry of Health will identify funding for the implementation of this policy. It will advocate with other ministries for resource allocation

Ministry of Health

Problem analysis features malnutrition Nutrition features as one of its key components – Community Based-Nutiriton Programme (CBNP) CBNP is one of the strategies of the national strategy to eliminate malnutrition and reflected in the action plan with corresponding costing

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TB non Communicable Diseases and HIV/AIDS Crosscutting:

Community Health Information Systems

Community Performance-based Financing (CPBF)

Community Health Workers Cooperatives

Social mobilization and Behavior communication and change

Supply chain for community case management

National Strategic Plan on HIV and AIDS

2009-2012 The overarching results that this plan will achieve by 2012 are as follows: 1. The incidence of HIV in the general population is halved by 2012 This will be achieved by:

Reduction of sexual transmission of HIV

Reduction of vertical (mother to child) transmission of HIV

Maintenance of low levels of blood-borne transmission of HIV

2. Morbidity and mortality among people living with HIV are reduced 3. People infected and affected by HIV have the same opportunities as the general population

120 million RwF per year for the next 5 years (PEPFAR). Other sources include Global Fund, and 5% from government contribution

Ministry of Health

The plan aims to ensure that all existing health centers are able to provide HIV testing and PMTCT services, as well as STI treatment services, and care and treatment for people living with HIV including nutritional support and psychosocial support. Nutrition specific support

Reinforcement of nutritional support for pregnant and lactating women and babies

Nutritional support, psychosocial and community support and palliative care.

Raise awareness of good nutritional practices among PLHA

Results are very well elaborated but there is no action plan included in the strategy to secure its operationalization

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Education

Early Childhood Policy

2011 Policy Goal: All Rwandan children achieve their potential, are healthy, well-nourished and safe, and their mothers, fathers and communities become nurturing caregivers through receiving integrated early childhood development services. Policy actions:

Operationalize policy and institutional framework to support ECD at all levels

Increase equitable access for all children aged 0-6 to adequate early stimulation, effective and relevant education, sufficient nutrition, quality health care and protection.

Strengthen effective public-private and international partnership supporting the integration of services, scale up & sustainability of ECD interventions

Evidence Based Programming and Effective Monitoring and Evaluation

Funding will be gerated through ministries’ l contribution from their own budget, and all other partners (no specific funding indicated)

Ministry of education

Nutrition features in the situation analysis and rationale of the policy: Holistic Early Child Hood Development services will greatly contribute to improved health and development outcomes, more specifically to reduced poverty; strengthened unity; improved child health and nutrition, educational efficiency……..

The policy actions are elaborated in the ECD implementation plan

Early Childhood Strategy and Plan

2011–2016

Strategic Objectives 1. Operationalize policy and institutional

framework to support the implementation of ECD at all levels

2. Increase equitable access for all children 0-6 years to adequate early stimulation, effective & relevant education, sufficient nutrition, adequate health care and protection

3. Strengthen effective public-private and international partnership supporting the integration of services, scale up & sustainability of ECD interventions in all imidugudu in Rwanda

4. Evidence Based Programming and Effective Monitoring and Evaluation

13,362,886,000 RwF

Ministry of Education

Nutrition features in the situation analysis and rationale: ECD forms the foundation of Basic Education programmes of MINEDUC; maternal and child health, nutrition and sanitation services… Implementation strategy specifc nutrition objectives

To improve health and nutrition care services

To reduce malnutrition and children under-5 child mortality and morbidity

To prevent and reduce stunted growth, and improve child

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Policy objectives:

To improve birth outcomes, reduce infant and maternal mortality and high fertility rates

To improve parents’ and legal guardians’ knowledge, skills and resources to support the development of their children

To reduce malnutrition and children under-5 child mortality and morbidity

To reduce the incidence of childhood illnesses and diseases

To ensure that all newborns are registered, the rights of all young children are respected and receive well-coordinated child protective services of high quality.

To provide comprehensive ECD services of high quality

To monitor and evaluate the organisation, coordination processes, programmes and services of the ECD Policy, and to promote research on key child development issues.

To sensitise local authorities, opinion leaders, parents, communities and journalists about the importance of ECD

To ensure infants and toddlers receive nurturing care and

development outcomes developmental services

Nutrition specific initiatives: Nutrition programme is included in ECD package with indicator on % of malnutrition rate decreased (at ECD centres) Support ECD Nutrition Programme budgeted: 3,608,640,000 RwF

School Health Policy

2012 (draft)

General Objective: To establish and improve healthy environment in schools by promoting physical, mental and psychosocial well-being of school children and promote health education. Strategies:

Advocacy

Capacity Development

Research on health issues

Integration of health into education curricula

Ministry of Education

Nutrition features in the situation analysis and rationale f the policy School nutrition is one of the policy actions:

Provide one balanced meal at least during study time per day

Initiate school gardening and farming activities at school

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(and in other sectors?)

Coordination and collaboration among stakeholders at all levels

Monitoring and Evaluation

Life skills development and transfer

Parents and community involvement/engagement, and ownership

Components and prioirity interventions:

Health Promotion & Prevention of disease

Environmental Health(Hygiene, Water and Sanitation, environment protection, …)

School Nutrition(School Feeding, Gardening and farming

HIV and AIDS, other STIs (Prevention, Impact mitigation, support and care)

Sexual, Reproductive Health & Rights (Sexuality Education, Family Planning , health services, SGBV prevention, related rights…)

Physical education and Sports

Mental Health & Psychosocial Care(Drugs abuse prevention and management, counseling and other services

where land is available

Carry out nutrition screening for all school children twice a year, refer severe malnutrition cases to the health center

Involve parents and community in school nutrition management, food provision, and meal preparation

Provide funding for basic requirements (school land, kitchen, running water, and energy/biogas or solar…)

Provide micronutrient supplementation and deworming as preventive measure of malnutrition

Involve school children in gardening activities balanced diet preparation so as for skills development

No implementation plan and budget

Social Protection

National social protection policy

2005 General objective: to give orientations to reduce vulnerability in general and the vulnerability of the poor and marginalized people in particular, and to promote a sustainable economic and social development centred on good social risk management and good coordination of savings actions and protection of vulnerable groups. Specific objectives: 1. To intensify protection measures for vulnerable groups and destitute people;

Ministry of Local

Government, Good

Governance, Community

Development and Social

Affairs

Malnutrition features in situation analysis and rational of the policy: The main problem faced by vulnerable children includes malnutrition Nutrition specific interventions:

Strengthen and to intensify nutritional programmes in a bid to protect households, especially children and the youth

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2. To contribute to poverty and vulnerability reduction through efficient social risk management; 3. To establish a coordination system for intervention in the area of social protection; 4. To promote savings’ initiatives and social security for all social groups in general and for vulnerable groups in particular; 5. To promote equity and social justice through socio- economic integration and equal opportunity for all in the development area. Strategies

Intensify measures meant to protect vulnerable groups and the destitute

Contribute to poverty and vulnerability reduction through efficient management of social risk

Establish a system for the coordination of interventions in the social protection area

Promote savings and social security initiatives for all social groups, particularly vulnerable ones

Promote social equity and justice through socio-economic integration and equal development opportunities for all

Promote not only the improvement of nutritional quality but also with the rationalisation of agricultural production

Reinforce child survival-oriented programmes by promoting breastfeeding, vaccination, fighting against most frequent causes of death (malnutrition, etc)

To intensify functional literacy for adults, especially women literacy, nutrition, modern agriculture and other practical techniques serving to meet daily life issues

No implementation plan and budget

National Social Protection strategy

2011-2016 Global Objective:To build a social protection system that tackles poverty and inequality, enables the poor to move out of poverty, helps reduce vulnerability and protect people from shocks, helps improve health and education among all Rwandans, and contributes to economic growth. Programmes

Build a comprehensive system of cash transfers

382,191million RwF

Ministry of Local

Government, Good

Governance, Community

Development and Social

Affairs

Malnutrition features in situation analysis and rational of the policy: Social protection will also impact directly on poverty and nutrition. It will increase incomes among poor and vulnerable households and enable them to purchase a wider and more nutritious range of food.

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Social protection programmes implemented by other sectors

Extension of contributory social security and labour standards

Social development initiatives to support social protection

Complementary services to social protection

Risk mitigation and responsiveness to shocks

Supports the EDPRS objective of improving nutrition services Nutrition is one of the complementary services The system of cash transfers and improved access to health and education services will directly tackle extreme poverty, while also contributing to improved nutrition; Social assistance include nutritional assistance with WFP support

Implementation Plan for the National Social Protection Strategy

2011-2016 Outcomes

Leadership, co-ordination and capacity on social protection strengthened across government

Social protection policies developed that are evidence-based and appropriate for rwandan context

Increased coverage of gender-sensitive social protection programmes that support the provision of a minimum income for families

Strengthened systems established for the delivery and monitoring of social protection programmes

Financial resources generated and sector-wide financial system developed to support delivery of social protection programmes

100,748 million RwF

Ministry of Local Government, Good Governance, Community Development and Social Affairs

Nutrition specific interventions not featured n the plan But, health and nutritional status of household members are indicated as potential areas for evaluation of social protection programmes

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D. Institutional framework linked to food security and nutrition

Main entities in charge of implementing the food and nutrition policy framework

20. The President’s call to ‘eliminate malnutrition’ as a national priority resulted in the formulation in 2010 of the National Multi-sector Strategy to Eliminate Malnutrition in Rwanda (NSEM). The plan was developed and is being implemented by a number of Ministries (Health, Education, Agriculture,Gender, Local Government, Infrastructure) led by the Ministry of Health and supported by UN Agencies and other International Organizations. Multi-sectoral committees have been established at central and local levels involving Mayors.

21. At national level. Government ministries typically lead the implementation of activities both at national and district levels. The key ministries responsible for implementing the NSEM are the Ministry of Health, Ministry of Agriculture, Ministry of Education, Ministry of Local Government, and Ministry of Gender and Family Promotions. In order to operationalize their commitment, the five ministries prepare a Joint Action Plan to Eliminate Malnutrition (JAPEM) on a yearly basis as a national platform to help track and support the implementation of the NSEM through DPEMs. The joint action plan supports the districts in implementing their respective District Plans to Eliminate Malnutrition.

22. At decentralized level, the district Mayors are responsible for eliminating malnutrition and coordinating nutrition activities. In order to operationalize the NSEM, the Ministry of Health together with its partners initiated the process of developing District Plans to Eliminate Malnutrition (DPEMs). This process was concluded in all the 30 districts in November 2011 with the culmination of the second annual nutrition Summit in 2011 where the plans were widely endorsed. All District Mayors have signed a performance contract with the Prime Minister’s Office with key nutrition indicators as follows:

Proportion of children < 5 years old screened for malnutrition using both MUAC and W/A during month growth monitoring sessions

Proportion of identified malnourished children < 5 years who are referred for appropriate management services

Proportions of household of all malnourished children who have been provided with support to establish kitchen garden

Proportion of mothers with children under 6 months who are adressed with Exclusive Breastfeeding promotional messages

Proportion of pregnant women receiving both Iron Folate (IF) supplementation and nutrition counseling at least 2 times during pregrancy

23. At hospitals, director of the hospital and a nutritionist is responsible for nutrition program implementation while the District agronomist is responsible of the food security component.

24. The GoR has established various convening bodies within the Government and at multi-sectoral levels (government ministries and all development partners for nutrition). The Ministry of Health is mandated to provide overall coordination of the implementation of the National Multi-sectoral Strategy to Eliminate Malnutrition or NMSEM (2010-2013). Oversight and coordination of the implementation of the above partnerships take place within the Rural Sector Cluster, Development Partners Coordination Group (DPCG), Budget Support Harmonization Group or any other body of similar consultative nature to be decided by the DPCG.

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Main technical and financial partners

Regional development Partners 25. Regional development partners include the African Union, COMESA and its regional partners are committed through the Maputo Declaration 2003, to support Rwanda in its endeavors to define priority programmes that would allow the country to meet the objectives of CAADP and be on the road to attaining MDG1. They support Rwanda’s national strategies as defined in the EDPRS and PSTA through mobilizing of political, financial and technical support.

National development Partners

UN Agencies 26. The UN organizations engage with the multi-sector/multi-stakeholder platform. It is an integral part of the DGP and TWGs where it provides technical leadership and financial assistance. The UN system actively participates at multi-sectoral level through the Nutrition Technical Working Group hosted by the Ministry of Health. It also participates in the Food Security and Nutrition Technical Working Group hosted by the Ministry of Agriculture. It supports strategic planning and analysis, advocacy, monitoring and evaluation as well as knowledge sharing for scaling up nutrition and food security.

27. In early 2011, Rwanda joined the SUN movement. The UN system has been instrumental in promoting the SUN Movement in the country. UN agencies coordinate nutrition support to through the REACH initiative. Support is focused in increasing awareness of the problem and potential solutions, strengthening national policies and programmes through technical assistance in the formulation/updating of nutrition policies, strategeies and plans at multi-sectoral and sectoral levels as well as at district level, enhance nutrition governance capacity at all levels, enchancing efficiency and accountability for the implementation of a multi-sectoral approach to eliminating malnitrition.

Multilateral/bilateral organizations 28. Donors engage with the multi-sector/multi-stakeholder platform through SWAP mechanism and in TWGs. They also have their own separate platform, which is the Development Partners Group (DPG) as a health sector (not limited to the nutrition sector). The Health DPG’s Group is a donor’s convening group consisting of donors and non- government health development partners, within the health sector group chaired by USAID. Lately, there has been an increased interest in nutrition by donor partners. Apart from those stakeholders who participated in the mapping exercise, other multilateral/bilateral development partnersalso also provide support. Below is the list of multilateral/bilateral organizations supporting nutrition:

Institutions Type of support

United States Agency for International Development (USAID)

Financial support (project based)

German International Cooperation (GIZ) Financial support

Great Mountain Coffee Roaster (GMCR) Financial support (project based)

European Union (EU) Health sector budget support

DFID Health Sector Budget support

Belgian Cooperation Health Sector Budget support

The Netherlands National budget support. Financial and technical support

(Discussion is on-going on possible support for nutrition as a key priority for the Dutch Multi-annual Plan (2012-2017)

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Institutions Type of support

World Bank National budget supportand technical assistance

African Development Bank (AfDB) Financial support

Canadian International Development Agency (CIDA)

Financial support (UN REACH) – supporting scaling up of food and nutrition security through strengthening multi-sectoral

coordination/approach to eliminate malnutrition)

Swiss for Development Cooperation(SDC) Financial support (e.g. food security analysis)

Local & International NGOs 29. NGOs supporting nutrition are coordinated through the Nutrition Technical working Group (NTWG). They typically operate at district level to implement specific nutrition activities direclty or through implementing partners. Below is the list of NGOs supporting nutrition in Rwanda:

S/N Name of organization (Acronyms) Name of organization in full

Main NGO Partner

1 CARE Care International

2 CARITAS Caritas Rwanda

3 CHF CHF International

4 CRS Catholic Relief Services

5 CWR Concern Worldwide Rwanda

6 FHI-360 Family Health International- 360

7 GHI Gardens for Health International

8 IRC International Rescue Committee

9 PIH Partners in Health

10 PATH Programme for Appropriate Technology in Health

11 SCR Send a Cow Rwanda

12 WRR World Relief Rwanda

13 WVI World Vision International

NGO Implementing Partner

1 ADEPR Association des Eglises des Pentecotes au Rwanda

2 ADRA Adventist Development and Relief Agency

3 AEE African Evangelistic Enterprise

4 AFRICARE Africare

5 AHA Africa Humanitarian Action

6 ARC American Refugee committee

7 DUHAMIC-ADRI Duharanire Amajyambere y'Icyaro (Kinyarwanda)/Action pour le Development Rural Interge

8 EPR Eglise Presbyterienne au Rwanda

9 FH Food for the Hungry

10 MCHIP Maternal and Child Health Integrated programme

11 PI Plan International

12 SAVE TC Save the Children

13 WIF Women Investment Fund

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Coordination Mechanisms

30. Within Government structure, the highest level convening body is the Inter-Ministerial Coordination Committee (IMCC) within the Prime Prime Minister Office (PMO) which meets every quarter under the leadership of the Minister of Health (MoH). This reviews information that is prepared by a low but similar committee, the IMCC of Permanent Secretaries (PS) of all ministries, also chaired by the PS of the MoH. This PS IMCC meets every month to review progress reports from their respective technical teams. Within the MoH itself, coordination is through weekly meetings of Senior Management (the SMM) which receives reports from the Maternal Child Health (MCH) Unit, under which are the Nutrition and Community Health Desks that manage implementation of nutrition related interventions.

31. At Multi-sectoral/stakeholder level, the highest body here is the Government of Rwanda (GOR) and Development Partner’s Group (DPG) consisting of all donors and development partners from various sector which is Co-Chaired by the Ministry of Finance and the UN Resident Coordinator. These are informed by sector-specific structures. Nutrition is a sub-sector under health where the multi-stakeholder coordinating body is the Health Sector Cluster’s Group (HSCG) consisting of government and all development partners in health and which Co-Chaired by MoH and the WHO. Within the HSCG, development partners (DPGs) convene on a monthly basis under the auspices of a 2-year rotational chair (the USAID is the current chair). Rwanda has adopted the SWAp mechanism and so technically, the HSCG is informed by various technical working groups (TWG) with the Maternal Child Health Group (MCH TWG) under which the Nutrition Technical TWG is managed, provides oversight and coordination for nutrition. Parallel coordinating bodies exist within the agriculture sector, i.e., the Agriculture Sector Working Group Co-Chaired by the Ministry of Agriculture and the World Bank and under this is the Food and Nutrition Security TWG Co-Chaired by Ministry of Agriculture and the FAO.

PMO

IMCC on nutrition of Ministers

IMCC on nutrition of PS

SM Meetings (MoH)

UM Meetings (MoH)

DPG

HSCG

HSTWG

MCH

NTWG

HDPG

ASG

FNSWG

Figure 8: Organogram

Government Convening Body Multi-sectoral convening Body

PMO

IMCC on nutrition of Ministers

IMCC on nutrition of PS

SM Meetings (MoH)

UM Meetings (MoH)

DPG

HSCG

HSTWG

MCH

NTWG

HDPG

ASG

FNSWG

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32. The Nutrition Technical Working Group (NTWG) coordinates interventions of all partners- UN agencies (UNICEF, WFP, WHO, FAO), national/international NGOs, the academic institutions, donors and private sector/corporation. The NTWG holds monthly meetings and is charged with provision of technical leadership on policy/strategy discussions and technical analysis and guidance for nutrition-related interventions for government and also for development partners. The key ministries represented at the technical committee are the Ministry of Health, Ministry of Local Governance, Ministry of Education, Ministry of Gender and Family Affairs and Ministry of Agriculture. Other government ministries attend meetings as needed. The secretariat is the Ministry of Health (MoH/Nutrition Desk) and the co-chair is USAID.

E. Analysis of current and future country nutritional actions & perspectives

Institutional framework & funding

Health Sector Programmes Government

allocated overall budget in Rwf

(for 2012)

External Partners (estimated valorized contribution in RwF – off

Government budget)

Performance Based Financing (PBF) 5.3 Billion RWF from Global Fund

Capacity building of providers 247,657,555 53.68 million (UNICEF/USAID)

Integration of nutrition management in the curriculum of A1 & A0

5,872,642

Nutrition screening of children between 6-59month 15,872,642

Supply of nutrition commodities for treatment of malnutrition cases

179,089,000 341.6 million (UNICEF/CWR/WVI)

Advocacy of Nutrition at all levels 4,039,000

Distribution of posters for health centers 1,000,000

Disseminate home garden booklets 1,539,000

Availability and accessibility of nutrition services 37,484,271

Training of the CHWs in all districts on growth monitoring program

3,830,189

Sensitization of community leaders on community based nutrition program

5,745,284

Support DPEM 5,000,000 122 million (UNICEF)

Source: MoH ( SUN Progress report September 2012)

Agriculture Sector Programmes Government allocated

overall budget in Rwf (for 2012/2013)

External Partners (estimated valorized

contribution in RwF – off Government budget)

Girinka 2.012.853.166

One cup of milk per child 1.000.000.000

kitchen garden 6.064.069

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Programmes Government allocated overall budget in Rwf

(for 2012/2013)

External Partners (estimated valorized

contribution in RwF – off Government budget)

kitchen garden at List 4 actors in each district are identified

2.228.242

810 kitchen garden units constructed 31.998.846

Promotion of vegetables on kitchen garden 6.411.800

food security and vulnerability 35.181.937

Source: MINAGRI (29 Jan 2013)

Main programmes being implemented to improve nutrition through multi-sectoral approach

Programmes

Ministry in charge of

the Program

Expected outcomes and target groups

Indicators Program Means of

Verification

Management of under nutrition (2010-2013) – All districts

MoH All children and pregnant and lactating women who are at risk of malnutrition are effectively identified, treated, followed up and integrated into community programs

Improved management of acute malnutrition; 100% nutrition commodities (CSB, RTFU, F100, F75) are available; Nutrition supervisory missions conducted

Rapid SMS Devinfo HMIS

Scaling up Community-based nutrition programme (2010-2013) - All districts

MINALOC All villages have adopted optimal IYCF practices, nutrition of pregnant and lactating mothers, appropriate hygiene practices, use of LLIN, family planning, HIVAIDS prevention and health insurance

National IYCF guideline approved; IYCF counseling sessions organized; Community mobilization for CBNP organized

Rapid SMS Devinfo HMIS

School Nutrition (2010-2013) – all school going children at primary and secondary school

MINEDUC All primary schools provide a hot and nutritious lunch to students; All students from nursery to primary schools receive a cup of milk twice a week; All schools with gardens; Nutrition education integrated into primary and secondary schools; All pupils in nursery and primary schools receive deworming tablets twice a year; All primary schools provide hand washing facilities to students; All students receive iron-folate supplements every year

Proportion of students receiving lunch at school Proportion of students receiving a cup of milk; Proportion of schools with gardens; Nutrition integrated into school curriculum; Proportion of student receiving deworming tablets; Proportion of schools with hand washing facilities; Proportion of students receiving iron-folate supplements

Devinfo HMIS

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Programmes


the Program



Verification

Improving Food Security at Household level (2010-2013)- all districts

MINAGRI MINALOC MOH

Improved protein intake; Improved HH dietary diversity; Promoted Income Generating Activities

Households with communal fish pond and practicing rabbit keeping ; Proportion of households consuming diverse diet ; Identified income generating activities by district

Devinfo HMIS FSNMS CFSVA

Improving the nutritional status of mothers and children in urban and peri-urban settings (2010-2013)- All urban and peri-urban districts

MINAGRI MINALOC MOH

Population mobilized and sensitized on nutrition; Kitchen gardens promoted

Proportion of population mobilized and sensitized on nutrition; Number of Kitchen gardens established

Devinfo HMIS

Eliminating micronutrient deficiency (2010-2013) – pregnant women and children from 6-24 months Home-based Food fortification/ Industrial Food fortification

MoH and Rwanda Bureau of Standards

Vitamins/mineral addition to staple foods 100% of children 6-59 months receive micronutrient supplements; 100% of women in post-partum receive a dose of vitamin A after delivery; 100% of pregnant women receive iron-folate during ANC; 100% of centrally processed foods identified in national legislation are fortified according to national standards; 100% of slat sold in Rwanda is iodized; 50% of children 6-24 months receive adequate fortified food complements (sprinkles or fortified complementary foods)

Iron fortification of staples Salt iodization; Vitamin A fortification of oil Proportion of children 6-59 months receiving micro-nutrient supplements; Proportion of women in postpartum receiving a dose of Vit A after delivery; Proportion of pregnant women receiving iron and folic acid supplementation; Proportion of centrally processed food with vitamin A, iron and folic acid and other essential vitamins and minerals as per national standards; Percentage of households using iodized salt; Percentage of children 6-24 months receiving fortified food complements at home

Devinfo HMIS

Multi-sectoral District Plans to Eliminate Malnutrition (DPEM) (2010-2013) – All districts

Ministry of Local Governance

100% of districts developed and implement DPEM

Proportion of districts with DPEM; Proportions of districts implementing DPEM

Supervision reports

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Programmes


the Program



Verification

Prevention and management of nutritional deficiencies and excess-related diseases (2010-2013) - All households (sensitized)

Ministry of Health

100% of HHs are sensitized on the risk factors and dangers associated with overweight and poor dietary combinations

Proportion of HHs sensitized

Devinfo HMIS

Behavior Change Campaign (2010-2013) –All villages and districts (receive messages)

Ministry of Local Governance and Ministry of Information

100% of villages received behavior change messages through different channels; All districts include behavior change communication in the DPEM

Proportion of villages receiving behavior change messages; Proportion of DPEM integrating behavior change communications

Supervision reports

Source: Rwanda National Strategy to Eliminate Malnutrition (2010-2013)

F. Analysis in Mainstreaming Nutrition in different sectors, and at the institutional level

On-going process within nutrition-linked regional and international initiatives

33. CAADP. In Africa, efforts to strengthen the contribution of the agriculture sector in reducing poverty are laid out in the CAADP Framework for African Food Security, which sets out a plan of action for achieving MDG1 in Africa through agriculture led growth. CAADP is therefore an opportunity for agriculture to engage in the “nutrition momentum” and join forces with other sectors in the fight against malnutrition. With support from CAADP and regional partners, Rwanda has developed a CAADP Compact in 2007, Agriculture Sector Investment Plan and/or Agriculture Development Strategy in 2009-2012).

34. SUN Initiative. Rwanda joined the SUN movement in early in 2012 with the Minister of Health as the SUN focal point. Although participation of Rwanda in the SUN movement is very recent, the engagement in the SUN Movement has advanced the national leadership and ownership of the scaling of up nutrition because it has demonstrated that government programmes and strategies to fight malnutrition are aligned to those recommended by the SUN Movement. The Government SUN Focal point has identified three priority commitments to advance nutrition scale-up in the next 12 months:

Leverage resources (financial & human) to support districts to implement their District Plans for the Elimination of Malnutrition

Strengthen monitoring systems for nutrition interventions including use of RapidSMS throughout the Continuum of Care during the 1000 Days

Strengthen multisectoral coordination mechanisms at both central and decentralized levels

REACH was introduced in Rwanda on February 2010. With funding from CIDA, REACH started operation in 2011. The REACH process is spearheaded by the heads of the four UN agencies and facilitated by neutral facilitators (international and national), who work together with the One UN country team in supporting government ministries, and other stakeholders to strengthen governance and management for scaling up nutrition.

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35. Agriculture sector7. Agricultural activities impact on household food security and individual nutritional well-being in different ways. If agriculture policies and programmes neglect to consider this impact, they miss the opportunity to improve the nutritional well being of the population, especially themost vulnerable groups. Pursuant to the NSEM, MINAGRI is expected to influence the following proceses: (a) contribute to the integration of the District Plans to Eliminate Malnutrition (DPEM) into the District Development Plans (DDP); (b) provide nutrition-sensitive agricultural inputs for the revision of the Economic Development and Poverty Reduction Strategy (EDPRS 2, July 2013 – June 2017);(c) mainstream nutrition in the Strategic Plan for the Transformation of Agriculture (PSTA III 2013/17); (d) contribute to the preparation of the next round of NSEM.

36. Until 2012, MINAGRI’s contribution to mainstreaming nutriton in policy and programme implementation was found to be weak. The Strategic Plan for the Transformation of Agriculture in Rwanda (SPTA 2, January 2009 – December 2012) has limited references to nutrition, and the sub-programme 1.6 (Food Security and vulnerability management) is not fully implemented. The NSEM includes several MINAGRI nutrition-related activities, but without a proactive contribution from MINAGRI. Some barriers still exist for a full integration of the nutrition aspects in the agricultural sector, including: a limited awareness, in particular about the positive and sometimes negative effects of the agricultural activities on nutrition; a still weak situation and response analysis; and some inconsistency between sector strategies from one side, and between national and decentralized action plans from the other side. Clear strategy is therefore needed with full set of initiatives to achieve the shift in focus from food production and agricultural growth to nutrition security. This will permit MINAGRI to ensure policy coherence and enhance its contribution in the fight against under-nutrition.

37. Although the process is gradual, strong political push towards mainstreaming nutrition in agriculture and better knowledge on the complexities of the causes of malnutrition have helped the MINAGRI to act more proactively. With EU and UN REACH agencies support, MINAGRI is in the processes of finalizing a Nutrition Action Plan 2013-2017. The plan interventions aim to achieve six strategic objectives: i) boosting the access to agricultural resources and affordable technology for those left behind; ii) diversifying food production and consumption at the household level mainly focusing on micronutrient–rich locally available foods and animal source foods in particular meat, eggs and milk; iii) providing new economic opportunities and ad hoc social transfer schemes for those most nutritionally insecure; iv) accessing food during the lean season leveraging optimal practices of food harvesting, storage and processing for the small-holders and establishing a strengthened early warning system to concretely support the decision making-process; v) sustain food markets through the amelioration of indigenous foods and milk value chains; vi) improve food and nutrition security governance. It also seeks to improve food and nutrition security governance through a strengthened coordination mechanisms on nutrition policy, programmes and initiatives at the national and sub-national levels, ensuring the influential contribution of the agricultural sector in initiatives and policy actions namely the National Food Fortification Alliance (NFA) and the implementation of District Plans to Eliminate Malnutrition (DPEM).

38. The new Strategic Plan for the Transformation of Agriculture (PSTA III 2013/17), currently being finalized, is a testament to the sector’s increasing attention to nutrition. For the first time, nutrition and household food security have been integrated as one of the sub-programme strategies.

7 Situation analysis from the draft Nutrition Action Plan 2012-2017, MINAGRI

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Coordination mechanisms and suggestions of improvement

At National level 39. In December 2012, the Nutrition Technical Working Group conducted an assessment of the Joint Action Plan to Eliminate Malnutrition (JAPEM 2012). One of the aspects being examined in the assessment is the appropriateness of the coordination mechanisms for the implementation of the JAPEM and the National Strategy to Eliminate Malnutrition (NSEM 2010-2013). The assessment pointed some strengths and weaknesses of the current coordination mechanisms through the Focused Group Discussion (FGD) conducted with partners8 .

40. The major strengths of the current coordinating mechanisms are:

Technical Working Groups meet consistently

Nutrition stakeholders mappings exists

There is a clearly defined National multi-sectoral Strategy to Eliminate Malnutrition

The approach is multi-sectoral - bringing together all relevant sectors (health, agriculture, local government, education, gender, ect) to work together to eliminate malnutrition

41. During the Focused Group Discussion (FGD) with nutrition partners conducted by the NTWG in December 2012, partners expressed that although the coordination structures are in place, coordination is weak. Ministries continue to work separately and there is no regular feedbacking of the status of the implementation of the joint action plans. Weak coordination was attributed to the following:

The reason and existence of the Joint Action Plan to Eliminate Malnutrition (JAPEM) have not being clearly and effectively communicated to all the relevant stakeholders, including the implementers

Coordination mechanisms for the JAPEM/NSEM implementation have not been clearly communicated by government ministries and partners concerned

Inadequate attention in formulating and harmonizing indicators and targets for the JAPEM

Progress reporting for JAPEM implementation is often inconsistent with the stated indicators, which makes objective assessment difficult

Planning cycle for JAPEM (January – December) was not aligned with the government financial year that runs from July to June

Insufficient integration of JAPEM activities into the respective annual ministerial plans

Limited sharing of JAPEM and NSEM documents with nutrition partners making most partners feeling left out and irrelevant

Poor communication between coordinators of coordination committees/technical working groups (TWGs) and nutrition partners , especially concerning notification of meetings

Unclear joint planning, reporting and monitoring and evaluation processes

Key implementing ministries are having difficulty in envisaging one of them to coordinate the other ministries

8 The draft report on the Joint Action Plan to Eliminate Malnutrition (JAPEM 2012) is still being finalized, Hence, the

assessment is mainly based on the FGD with partners held in Dec 2012.

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In addition, the Ministry of Agriculture it pointed out that cross-ministerial coordination is problematic, referring to weak linkages to specific ministries such as Ministry of Health in relation to malnutrition9.

42. The same FGD recommended a set of recommendations for the aspects of the current mechanisms at national level that should be improved:

Introduction of one coordination Forum for the different sector TWGs

Increasing pro-activeness in monitoring and evaluation within TWG with regard to tracking JAPEM implementation

Conducting annual joint supervision of the district Plans to Eliminate Malnutrition (DPEM)

A more balanced representation /participation of the relevant sectors in the TWGs

Planning process for JAPEM and NSEM to adequately include nutrition partners

At district level10 43. At district, multi-sectoral committees to eliminate malnutrition at all levels were established to coordinate the implementation of the district plan under theoverall leadership of the District Mayors. One very positive aspect of the DPEM implementation is the high level of commitment of the district authorities (in some districts) emanating from the office of the Mayors, which has significantly contributed to the start up of the DPEM implementation. In districts where Mayor’s commitment is percieved to be high, multisectoral committees were also found to be functional. These committees were also found to be functional in districts where the DPEMs are widely shared and accepted by the sector authorities.

44. In contrast, districts where Mayor’s commitment is lacking, the multisectoral committies were found to be largely non-existing or non-functional owing to weak linkages between DPEM implementers at district level and partners:

The DPEM has not been shared to the sector authorities

Lack of budget support for transport and per diem of committee representatives coming from the sectors.

Lack of inofrmation concerning the multisectoral committee

Lack of terms of reference and guidelines

Lack of follow up especially from the district level

Irregular committee meetings

Imbalanced attendance to meetings by committee members (often, only Community Health Workers attend meetings and/or with health centre staff)

Lack or limited support from partners concerning DPEM implementation in the district

45. Based on the supervision done by the NTWG during mid 2012, a set of recommendations were given to improve coordination at district level:

Develop and communicate clear terms of reference for the multi-sectoral coordination committees at the different levels

9 EDPRS Self- Assessment Report, Dec 2011, Ministry Of Agriculture and Animal Resources

10 National Joint Supervision on District Plan to Eliminate Malnutrition (DPEM) Draft Report, June 2012, Ministry of

Health

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Encourage partners to align their annual action plans with the DPEMs of the districts they are supporting

Increase budget support and improve budegt coordination from central to district level - from GOR and partners through the NTWG and JAPEM framework

Monitoring & Evaluation mechanisms

46. There are various mechanisms supporting the implementation of the current national strategy to Eliminate Malnutrition. Nutrition as a sub-sector under Health sector is also monitored through this established Health Monitoring and Information System or HMIS. The HMIS carry out regular M&E for key nutrition indicators (height- for- age, Weight- for – Height, and weight-for-age). This information is regularly collected through district monitoring platforms such as SIScom or community Health Information System and CBHI monthly indicators. Growth monitoring and promotion is widely practiced. This is one activity that can be counted on to be happening almost everywhere. Rapid SMS has also been used to provide real time community based surveillance and alert system for maternal and child health. Some of its key features includes registration of pregant mothers, reminders for pre-natal and ante-natal check ups and tracking bith, death, and other vital statistics of the fetus and newborn. Recently, plans are underway to use the Rapid SMS system to also support the monitoring across the 1000 day window of opportunity. Rwanda has also piloted the use of Devinfo system as a comprehensive system for monitoring the progress of the DPEM implementation. There are also plans for expanding this system at central level.

47. Monitoring and evaluation of the NSEM and related action plans remains challenging. Development partners expressed that planning, reporting and M&E processes in unclear. Reporting. Baseline data have not been established, and progress reporting does not adhere to the stated indicators of the plan. Thus reporting remains subjective, making objective assessment of achievements difficult11. Communication and feedbacking of the status of implementation had also been poor. Finally in some districts, lack of materials and equipment limited the coverage of growth monitoring12.

Main Management and Technical Capacities at the Institutional level

48. Rwanda has shown impressive progress towards achieving its Economic Development and Poverty Reduction strategy goals for 2008-2012: the share of the population living in poverty from 56.9% in 2005/6 has reduced to 46% in 2012/13 and the target of achieving extreme poverty from 37% in 2005/6 to 24% has also been met. A strong decline in under 5 malnutrition was also noted, with a decrease from 18% of children under weight in 2006 to 11% in 2010/11. These were possible thanks to (a) working together with participation of population; (b) home-grown initiatives driving strengthened delivery of services; (c) ownership of the EDPRS by all stakeholders and alignment of all resources to this framework (making the EDPRS a useful guiding strategy); (d) putting in place an adequate institutional/legal framework for implementation; (e) improved delivery through ICT based solutions; and (f)performance contracts with District Mayors, which is seen to have facilitated progress and helped ensure focus on delivery of results13.

11

JAPEM Assessment: Focused Group Discussion with partners held in Dec 2012. 12

DPEM Supervision Report (Draft) June 2012 13

EDPRS Lessons Learned: 2008-2011, Ministry of Finance and Economic Planning

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49. Some shortcomings however have also been noted: (a) some sectors still lack exhaustive and well articulated strategies, including financing and capacity mobilization; (b) mainstreaming cross-cutting issues needs improvement; (c)insufficient coordination and communication across sectors; (d) insufficient involvement of the private sectors; (e) weak M&E systems; (f) delays due to poor procurement planning and insufficient capacity of private contractors; and (g) quality of service delivery needs improvement14.

Main issues at stake to improve the mainstreaming and scaling up of nutrition at the country level and regional/international level

50. Overall, Rwanda’s multi-sectoral approach enjoys a coherent policy and legal framework, with strong political leadership and commitment at the highest levels. There is an increasing interest and better engagement from development partners, including Civil Society Organizations (CSOs). Addressing malnutrition through a multi-sectoral approach however carries along coordination and implementtion challenges, which the government still needs to overcome:

Problematic cross-ministerial coordination- ministries continue to work in separately coupled with poor feedbacking of the status of the implementation of the joint action plans. There are weak linkages with other ministries such as with the MoH in relation to malnutrition15

There is a need to strengthen the Nutrition strategy M&E system – an integrated M&E linking districts and sectors with the national system

There is a need for increased participation from development partners particularly to support implementation of nutrition interventions

Despite gaining top government support through successful advocacy efforts, securing the necessary technical and financial support to implement what have been agreed remains a challenge

Current costing figures of the Nutrition Action Plans are based on estimates and there are challenges in tracking actual contributions and expenditures. Hence the need for improving costing and using more standardized methodology.

14

EDPRS: Lessons Learned 2008-2011 15

MINAGRI EDPRS Self-Assessment Report, Dec 2011

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Annex 1- Definitions

Multi-stakeholder approaches

Working together, stakeholders can draw upon their comparative advantages, catalyze effective country-led actions and harmonize collective support for national efforts to reduce hunger and under-nutrition. Stakeholders come from national authorities, donor agencies, the UN system including the World Bank, civil society and NGOs, the private sector, and research institutions.

Nutritional Security

Achieved when secure access to an appropriately nutritious diet is coupled with a sanitary environment, adequate health services and care, to ensure a healthy and active life for all household members.

Severe Acute Malnutrition (SAM)

A weight-for-height measurement of 70% or less below the median, or three standard deviations (3 SD) or more below the mean international reference values, the presence of bilateral pitting edema, or a mid-upper arm circumference of less than 115 mm in children 6-60 months old.

Stunting (Chronic malnutrition)

Reflects shortness-for-age; an indicator of chronic malnutrition and it is calculated by comparing the height-for-age of a child with a reference population of well-nourished and healthy children.

Underweight Measured by comparing the weight-for-age of a child with a reference population of well-nourished and healthy children.

Wasting

Reflects a recent and severe process that has led to substantial weight loss, usually associated with starvation and/or disease. Wasting is calculated by comparing weight-for-height of a child with a reference population of well-nourished and healthy children. Often used to assess the severity of emergencies because it is strongly related to mortality. Source : SUN Progress report 2011

Acute hunger Acute hunger is when the lack of food is short term, and is often caused when shocks such as drought or war affect vulnerable populations.

Anaemia

Anaemia, defined by the World Health Organization (WHO) as haemoglobin (Hb) concentration below the established cut-off levels (11.0g/dL in children under five years of age) represents one of the world’s most serious health risk factors. Iron deficiency is one of the main contributing factors of anaemia, with major consequences for human health including premature death, impaired mental and physical growth, social and economic development due to reduced work and cognitive performance and productivity .

Chronic hunger Chronic hunger is a constant or recurrent lack of food and results in underweight and stunted children, and high infant mortality. “Hidden hunger” is a lack of essential micronutrients in diets.

Direct nutrition interventions and nutrition-sensitive strategies

Pursuing multi-sectoral strategies that combine direct nutrition interventions and nutrition-sensitive strategies. Direct interventions include those which empower households (especially women) for nutritional security, improve year-round access to nutritious diets, and contribute to improved nutritional status of those most at risk (women, young children, disabled people, and those who are chronically ill).

Food Diversification

Maximize the number of foods or food groups consumed by an individual, especially above and beyond starchy grains and cereals, considered to be staple foods typically found in the diet. The more diverse the diet, the greater the likelihood of consuming both macro and micronutrients in the diet. Source : FAO

Food security

When all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life.

Hunger Hunger is often used to refer in general terms to MDG1 and food insecurity. Hunger is the body’s way of signaling that it is running short of food and needs to eat something. Hunger can lead to malnutrition.

Iron deficiency anemia

A condition in which the blood lacks adequate healthy red blood cells that carry oxygen to the body’s tissues. Without iron, the body can’t produce enough hemoglobin, found in red blood cells, to carry oxygen. It has negative effects on work capacity and motor and mental development. In newborns and pregnant women it might cause low birth weight and preterm deliveries.

Malnutrition

An abnormal physiological condition caused by inadequate, excessive, or imbalanced absorption of macronutrients (carbohydrates, protein, fats) water, and micronutrients.

Millennium Development Goal 1 (MDG 1)

Eradicate extreme poverty and hunger, which has two associated indicators: 1) Prevalence of underweight among children under five years of age, which measures under-nutrition at an individual level; and, 2-Proportion of the population below a minimum level of dietary energy consumption, that measures hunger and food security, and it is measured only at a national level (not an individual level). Source : SUN Progress report 2011

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Annex 2: Acronyms

ADEPR Association des Eglises des Pentecotes au Rwanda

ADRA Adventist Development and Relief Agency

AEE African Evangelistic Enterprise

Afdb African Development Bank

AFRICARE Africare

AHA Africa Humanitarian Action

ARC American Refugee committee

ASIP Agricultural Sector Investment Plan

ASWG Agriculture Sector Working Group

BCC Behaviour Change Communication

CAADP Comprehensive Africa Agriculture Development Programme

CARE Care International

CARITAS Caritas Rwanda

CBNP Community Based Nutrition Project

CFSVA/NS Comprehensive Food Security and Vulnerability Analysis and Nutrition Survey

CHF CHF International

CIDA Canadian International Development Agency

CRS Catholic Relief Services

CWR Concern Worldwide Rwanda

DDP District Development Plan

DFID DFID

DPEM District Plans to Eliminate Malnutrition

DPEM District Action Plans to Eliminate Malnutrition

DPG Development Partners Group

DPG Development Partner’s Group

DUHAMIC-ADRI Duharanire Amajyambere y'Icyaro (Kinyarwanda)/Action pour le Development Rural Interge

EDPRS Economic Development and Poverty Reduction Strategy

EICV Enquête Intégrale sur les Conditions de Vie des ménages EPR Eglise Presbyterienne au Rwanda

EU European Union

FAO Food and Agriculture Organization

FCS Food Consumption Score

FGD Focused Group Discussion

FH Food for the Hungry

FHI-360 Family Health International- 360

FS Food Security

FSNWG Food Security and Nutrition Working Group

GDP Gross Domestic Product

GHI Gardens for Health International

GIRINKA One cow per family project

GIZ German International Cooperation

GMCR Great Mountain Coffee Roaster

HIV/AIDS Acquired Immune Deficiency Syndrome

HSCP Health Sector Cluster’s Group

HSSP Health Sector Strategic Plan

HSSP Health Sector Strategic Plans II

HSWG Health Sector Working Group

IGA Income Generating Activities

IMCC Inter-Ministerial Coordination Committee

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IRC International Rescue Committee

IYCF National Strategy for infant and Young Child Feeding

JAPEM Joint Action Plan to Eliminate Malnutrition

JAPEM Joint Action Plan to Fight Malnutrition

M&E Monitoring and Evaluation

MCHG Maternal Child Health Group

MCHIP Maternal and Child Health Integrated programme

MCHTWG Maternal and Child Health Technical Working Group

MDG Millennium Development Goal

MIGEPROF Ministry of Gender and Family Promotion

MINAGRI Ministry of Agriculture and Animal Resources

MINALOC Ministry of Local Government

MINECOFIN Ministry of Finance and Economic Planning

MINEDUC Ministry of Education

MIS Management Information System

MOH Ministry of Health

MoU Memorandum of Understanding

NAEB National Agriculture and Export Board

NAP Nutrition Action Plan

NCHS National Centre for Health and Statistics

NGO Non-Governmental Organization

NISR National Institute of Statistics of Rwanda

NSEM Multisectoral Strategy (and action plan) to Eliminate Malnutrition

NSEM National Multi-sectoral Strategy to Eliminate Malnutrition

NTWG Nutrition Technical Working Group

NTWG Nutrition Technical Working Group

PATH Programme for Appropriate Technology in Health

PBF Performance Based Financing

PI Plan International

PIH Partners in Health

PMO Prime Prime Minister Office

PS Permanent Secretaries

PSTA Strategic Plan for the Transformation of Agriculture (PSTA II)

RDHS Rwanda Demographic and Health Survey

REACH Renewed Efforts Against Child Hunger and under-nutrition

RIDHS Rwanda Interim Demographic and Health Survey - 2010

SAVE TC Save the Children

SCR Send a Cow Rwanda

SDC Swiss for Development Cooperation

SUN Scaling Up Nutrition

ToR Terms of Reference

TWG Technical Working Group

UNDAF UN Development Assistance Framework for Rwanda

UNDP

UNICEF United Nations International Children’s Emergency Fund

USAID United States Agency for International Development

USD United States Dollar

WB World Bank

WFP World Food Programme

WHO World Health Organization

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WIF Women Investment Fund

WRR World Relief Rwanda

WVI World Vision International

comprehensive africa agriculture development programme ... · prevalence of anemia among pregnant...

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