programme budget 2014 2015 performance assessment...

PBPA2014-2015 (April 2016) 1 PA: 2.5 Nutrition

Programme budget 2014–2015 performance assessment Programme area: 2.5 Nutrition

OUTCOME 2.5. REDUCED NUTRITIONAL RISK FACTORS

I. OVERVIEW OF MAJOR ACHIEVEMENTS AND CHALLENGES Overall, the biennium has been a remarkable couple of years for nutrition, with the organization of the Second International Conference on Nutrition (ICN2) in 2014 and the adoption of the 2030 Agenda for Sustainable Development in 2015. Nutrition is high on political agendas and alignment by nutrition actors on vision, policies and strategies is greatly improving. Nutrition is now strongly embedded in the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030). WHO has been a visible advocate of nutrition, despite challenges of competition for attention internally and externally. The six WHO global nutrition targets, endorsed by the World Health Assembly in 2012, have proven to be an excellent advocacy instrument for nutrition and a stimulus for Member States to establish their own national targets and commitments for nutrition. In all regions and in headquarters, nutrition work is now fully encompassing the double burden of malnutrition. Regional and country plans are updated to reflect not only the full spectrum of malnutrition problems but also the commitments, goals and targets of ICN2 and the Sustainable Development Goals (SDGs). Increasingly, legal instruments and tools (such as the nutrient profiles) are being used to in the fight against malnutrition in all its forms. The lack of human resources and technical capacities is a challenge, and countries request support. Overall, nutrition data gaps remain an issue. WHO has developed and published evidence-informed guidelines to support public health strategies in several areas related to nutrition interventions and healthy diets. These include fortification of food-grade salt with iodine for the prevention and control of iodine deficiency disorders; recommendations for optimal serum and red blood cell folate concentrations in women of reproductive age for prevention of neural tube defects; the role of delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes; nutritional care of children and adults with Ebola virus disease in treatment centres; and the updated guidelines on sugar intake for adults and children. WHO’s evidence-informed guidelines are available online and through the WHO e-Library of Evidence for Nutrition Actions (eLENA) portal. Norms, standards and systems are put in place at regional and country levels to support countries to achieve the six global nutrition targets. Lack of financial and human resources remains a serious challenge.


II. OUTPUT MEASUREMENT

Output 2.5.1 Countries enabled to develop, implement and monitor action plans based on the maternal, infant and young child nutrition comprehensive implementation plan

Output indicator

Baseline

Target

Achieved value

Number of countries that are implementing national action plans consistent with the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition

38 45 76

Overview of achievements and challenges

In 2014 WHO and the Food and Agriculture Organization of the United Nations (FAO) jointly convened the Second International Conference on Nutrition (ICN2), a high-level intergovernmental meeting attended by over 2200 participants from 170 countries that focused global attention on addressing malnutrition in all its forms. The two main outcome documents – the Rome Declaration on Nutrition and the Framework for Action – commit world leaders to establishing national policies aimed at eradicating malnutrition and transforming food systems to make nutritious diets available to all. WHO remained a solid and trusted partner in global interagency bodies, such as the United Nations Standing Committee on Nutrition (UNSCN), the Renewed Efforts against Child Hunger (REACH) initiative, the Scaling Up Nutrition (SUN) movement, and the Secretary-General’s High-Level Task Force on the Global Food Security Crisis. WHO carried out a survey on the adoption of the International Code of Marketing of Breast-milk Substitutes. Code-related legislation is now available through the WHO Global Database on the Implementation of Nutrition Action (GINA). With support from the Scientific and Technical Advisory Group on Inappropriate Promotion of Foods for Infants and Young Children, WHO developed a draft guidance document, which was discussed in informal consultations with Member States, United Nations agencies, NGOs in official relations and private sector entities, and which was also submitted for public comments. WHO convened a technical consultation on conflict of interest in the process of developing risk assessment and management tools for nutrition programmes at national and international level. Progress was made on a global monitoring framework on maternal, infant and young child nutrition, including a set of 20 core indicators to be reported on by all countries. WHO and the United Nations Children’s Fund (UNICEF) have jointly established a Technical Expert Advisory Group on Nutrition Monitoring (TEAM) to support the implementation of the global monitoring framework. WHO contributed to the production of two editions of the Global nutrition report. The report’s assessment of the global nutrition targets for 2025, endorsed by the World Health Assembly, shows that the world is not on track to meet any of these goals. In the African Region: The major achievement was the inclusion of the six global nutrition targets for 2025 in the African Regional Nutrition Strategy, adopted by the African Union Heads of State. This is a clear endorsement of the relevance of the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition at continental level. Furthermore, The Regional Office for Africa contributed to the development of a strategy and framework for resilience in the Sahel, and the Comprehensive Africa Agriculture Development Programme results framework for monitoring nutrition outcomes in agriculture programmes.


Nine countries updated policies, strategic plans and regulations relating to some or all of the six global targets of the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition or the five action areas proposed for Member States’ contribution to implementation of the plan, while monitoring and evaluation frameworks for the plan were strengthened in 12 countries by incorporating nutrition indicators into existing information systems with capacity-building to collect data through routine health visits or sentinel systems. A large initiative on nutrition surveillance was implemented with funding from Canada – the Accelerating Nutrition Improvements (ANI) project. ANI strengthened nutrition monitoring services for over 17% of the districts in 11 countries, reaching almost 23 million women of reproductive age, and 12 million children aged under 5 years. WHO supported strengthening nutrition surveillance systems in Burkina Faso, Mali, Mozambique, Rwanda, Senegal, Sierra Leone and Zimbabwe. WHO also supported nutrition surveys in Mali, Rwanda, Senegal, Sierra Leone, Zambia and Zimbabwe. WHO strengthened the capacity of more than 1600 health workers in nine countries on various aspects of nutrition surveillance. In addition, WHO strengthened the capacity of more than 1800 health workers, community health workers, and government officials in Ethiopia, Uganda and the United Republic of Tanzania on the delivery of essential nutrition actions through health care systems and on behavioural change communication. In the Eastern Mediterranean Region: A regional nutrition roadmap was developed for and with Member States to implement ICN2 recommendations and activities to reach the global nutrition targets. National strategies and action plans to implement ICN2 recommendations were developed in several countries, including Morocco, Pakistan, Somalia and Sudan. The Regional Office developed a policy statement to implement the International Code of Marketing of Breast-milk Substitutes in the Region. Many countries (Afghanistan, Bahrain, Kuwait, Oman, Pakistan, Palestine, Saudi Arabia and Syria) have already developed nutrition surveillance systems and are generating data on a regular basis for most of the indicators. Pakistan, Somalia, Sudan and Yemen became members of the SUN movement. In the European Region: A new European Food and Nutrition Action Plan 2015–2020 was adopted at the 64th session of the Regional Committee, built on the commitments of the Vienna Declaration on Nutrition and Noncommunicable Diseases in the Context of Health 2020, aligned with ICN2 commitments. The Regional Office for Europe has been providing technical support to Member States in priority areas of the plan, i.e. food systems and healthy food environment, the importance of paying special attention to vulnerable groups, the need to foster health systems to respond to nutrition-related diseases and the implementation of sound intersectoral governance mechanisms. A world-leading Childhood Obesity Surveillance Initiative has been established in the region, collecting nationally represented, measured and internationally comparable data on overweight and obesity among primary schoolchildren (in 31 Member States). In the South-East Asia Region: The nutritional status of infants and young children is far from optimal in this Region. Despite efforts from Member States, undernutrition continues to be a major problem, with unacceptably high levels of moderate to severe stunting and low birth weight. Of the 10.5 million deaths annually among children under 5 years of age in the countries of the Region, 40% are associated with undernutrition. Overweight and obesity are also emerging in the region. Food and nutrition strategies and action plans were developed in four Member States (Bhutan, Democratic People’s Republic of Korea, Myanmar, Timor-Leste). Seven Member States have developed action plans and are implementing elements of the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition, with technical inputs from WHO. Continued advocacy has been carried out to promote the plan and to develop national nutrition targets based on the six global nutrition targets. All countries have adapted and use the WHO growth charts.


In the Western Pacific Region: The Regional Action Plan to Reduce the Double Burden of Malnutrition in the Western Pacific Region (2015–2020) was approved at the Regional Committee meeting in 2014 and guides the work of the regional nutrition programme. In support of the action plan, regional workshops were held to facilitate implementation and monitoring, including the development of a monitoring framework and baseline country profiles. Country and regional offices provided technical and legal support to Cambodia, Lao People’s Democratic Republic, Malaysia, Mongolia, the Philippines, Viet Nam, and several Pacific Island countries, including Cook Islands, Fiji, Kiribati, Samoa, Solomon Islands, Tonga and Tuvalu, to advance implementation of legal instruments to improve nutrition. WHO also supported nutrition surveillance activities in six countries in the Western Pacific Region (China, Fiji, Kiribati, Lao People’s Democratic Republic, Solomon Islands and Tuvalu). Interagency coordination and collaboration was strengthened through the development and publication of the first United Nations Global Nutrition Agenda, which was introduced and presented to the region at the United Nations Regional Nutrition Meeting for Asia and the Pacific. The initial focus of interagency collaboration has been on updating national protocols on the integrated management of acute malnutrition and joint advocacy. In the Region of the Americas: A Plan of Action for the Prevention of Obesity in Children and Adolescents was unanimously approved at the 53rd Directing Council. This five-year plan (2014–2019) addresses the World Health Assembly nutrition targets for exclusive breastfeeding and overweight and commits Member States to take actions to improve young child feeding and school nutrition, adopt fiscal and regulatory policies to discourage the consumption of energy-dense, nutrient-poor foods, adopt multisectoral policies to improve the food and physical activity environments, and develop surveillance and monitoring systems. To develop the plan of action, subregional meetings were held in the Caribbean and Latin America. National plans to implement the plan of action were developed in Barbados, Honduras and Puerto Rico. As part of a broader PAHO initiative to document existing laws related to the prevention of noncommunicable diseases (NCDs), legislation related to fiscal and regulatory policies to prevent obesity was obtained and analysed. Technical support for implementation of laws and regulations to prevent obesity was provided to Barbados, Bolivia, Mexico, Peru and Puerto Rico. Technical support for legislation and monitoring of the International Code of Marketing of Breast-milk Substitutes was provided to Bolivia, Chile, Colombia, Honduras and Mexico.

Achievements and challenges in countries

Over 50 countries have been reviewing their national food and nutrition action plans in 2014–2015 with WHO support, including reference to the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition and the outcomes of ICN2 (11 in The African Region, 3 in the Region of the Americas, 7 in the South-East Asia Region, 22 in the European Region, 9 in the Eastern Mediterranean Region, and 6 in the Western Pacific Region). In the 11 countries of the African Region that had earmarked funding for accelerated improvements in nutrition (Burkina Faso, Ethiopia, Mali, Mozambique, Rwanda, Senegal, Sierra Leone, Uganda, United Republic of Tanzania, Zambia and Zimbabwe), scale-up plans have been developed for improving nutrition and surveillance systems have been strengthened. National nutrition policies, strategies and plans aligned with the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition have been developed or updated in Guinea, Malawi, Rwanda, South Sudan, Swaziland, Zambia and Zimbabwe. In Benin a national policy for nutrition-friendly schools has been developed. Challenges include the limited financial and human resource capacities. Fostering partnerships with other stakeholders requires time investments that WHO country office staff can barely afford, given that most are focal points for many other programmes (for example reproductive, maternal, newborn, child and adolescent health, HIV and NCDs). The pace of implementing nutrition surveillance plans and activities depends on timetables set by custodians of the parent programmes in which they are integrated (taking into account health management information systems and data management information systems), which poses challenges for timely achievement of results.


In the Eastern Mediterranean Region resources were mobilized in Afghanistan, Iraq, Libya, Pakistan, Sudan, Syria and Yemen to support the implementation of the maternal, infant and young child nutrition plans. Kuwait and Qatar used their national resources to fund nutrition work plans. Implementation of the nutrition work plans in Libya and Yemen are at risk due to the ongoing security situation and internal conflict. A regional assessment was conducted in 2014 to assess the implementation of the International Code of Marketing of Breast-milk Substitutes. Out of 22 Member States, only five countries have fully implemented the International Code: Afghanistan, Bahrain, Lebanon, Pakistan and Yemen. Ten Member States had partial implementation: Djibouti, Egypt, Islamic Republic of Iran, Jordan, Kuwait, Oman, Palestine, Saudi Arabia, Sudan and Syria. Countries that have no implementation of the International Code are Iraq, Libya, Morocco, Qatar, Somalia and United Arab Emirates. Nutrition surveillance systems have been established and are functioning in many countries. The main challenges are the inadequate capacity in ministries of health to programme and implement the nutrition activities due to limited staff at provincial and community levels and limited accessibility to the remote areas due to the security situation, especially in countries with emergencies. In the European Region, Member States carried out evaluations of national plans and translated data and examples on what works in specific country contexts. This work has included trans fat elimination and saturated fat reduction, marketing foods to children, salt reduction and food taxation policies. In the South-East Asia Region, national nutrition and health authorities from Member States have been briefed on the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition and its implementation, and most national nutrition programmes in Member States now include key targets related to the Comprehensive Implementation Plan (reduction of anaemia, addressing wasting and stunting, and promoting breastfeeding). WHO helped most Member States develop food-based dietary guidelines and coordinated the participation of Member States in ICN2. In the Western Pacific Region, most national nutrition action plans of island countries have been aligned with national NCD strategies and plans. Enforcement of legislation to protect and promote breastfeeding was supported in Cambodia. A multisectoral nutrition plan that integrates health, agriculture and education was supported in Lao People’s Democratic Republic, as well as a scoping exercise for a national nutrition law. The Infant and Young Child Nutrition and the Nutrition in Emergencies strategies were supported in Mongolia, and the midterm review of the National Plan of Action on Nutrition in the Philippines. Nutrition-related surveys were conducted with WHO support, including a national nutrition survey in Fiji, baseline salt assessments and application of the STEPwise approach to chronic disease risk factor surveillance (STEPS) in selected island countries, as well as an anaemia survey to monitor implementation of weekly iron-folic acid supplementation in Lao People’s Democratic Republic. A report on the nutrition and health situation of the left-behind children in Shaanxi Province of China was developed.

Achievements and challenges at regional and global levels The main progress at global level pertains to the broad adoption of the six targets of the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition, the approval of the ICN2 outcome documents and the agreement on indicators of the Global Nutrition Monitoring Framework. Advances have been made on birth defects surveillance, in relation to the folate status of populations. The challenge is the proliferation of partnerships and global initiatives on nutrition, requiring a large investment in time and a focus on the comparative advantage of WHO. In the African Region, global nutrition targets for 2025 have been included in the Africa Regional Nutrition Strategy. Challenges are linked to financial and human resource limitations. For example, the nutrition focal point position of the inter-country support team remains vacant for lack of budget, yet there is great need to support nutrition activities in a subregion that is home to some of the neediest countries. Key staff in the region are supported by specified project funds, and this is a challenge to sustainability. In the Eastern Mediterranean Region, the regional action plan has been developed, implemented and evaluated, including elements of maternal, infant and young child nutrition. Nutrition has also been integrated through the regional maternal and child health acceleration plans. Taking advantage of ICN2, the Regional Office has promoted interagency and multisectoral coordination on healthy diets, food and nutrition security at regional level, and catalysed partnerships by linking with stakeholders, especially from non-health sectors.


The major challenge in the Region is the limited staff. The management has decided to recruit a technical officer to assist the regional adviser. In the European Region, the 2015–2020 European Food and Nutrition Action Plan was approved. The Regional Office has developed a nutrition policy appraisal tool, guidance for use of price measures and other behaviour change interventions, and convened a workshop on marketing of food to children, now involving 12 Member States. The European Nutritional Status Project now involves 25 Member States. Intercountry action networks have been maintained and expanded. The Regional Office has complemented country office capacity in providing technical support in the area of nutrition to Member States, particularly on the measures to reduce the negative impact of unhealthy diets, with a focus on vulnerable groups. However, the relatively limited funding available to support country work and the restricted staff availability challenge the ability to provide support to countries. In the South-East Asia Region, a regional workshop on nutrition guidelines and recommendations has reviewed the overall Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition in Member States and identified mechanisms for expediting its development, implementation and monitoring components. Technical and financial support was provided to the organization of an international conference on micronutrients. Challenges rest in the implementation of the actions suggested in the Comprehensive Implementation Plan, specifically the multisectoral action. In the Western Pacific Region, a 2015–2020 Action Plan to Reduce the Double Burden of Malnutrition was developed. Challenges include policy incoherence in nutrition, industry interference in policy development and implementation, weak health systems, lack of capacity of the workforce to deliver nutrition services, and lack of infrastructure to monitor implementation of national plans aligned with the Comprehensive Implementation Plan. In addition, challenges in most countries include positioning WHO amidst the numerous actors working on nutrition. WHO has a clear and unique mandate vis-à-vis other actors in nutrition, given its focus on strengthening health systems to facilitate delivery of essential nutrition services, specifically to vulnerable populations, and supporting policy development and implementation free from conflict of interest. Lack of human and financial capacity at country level poses a real challenge to achieving the output. Challenges in some countries also include recent political change resulting in frequent turnover of staff (for example Mongolia). Due to lack of resources for nutrition, most countries were unable to fully implement planned activities. In the Region of the Americas, a Regional Plan of Action on Childhood Obesity was approved.

Risks and assumptions The 2014–2015 risk register The 2014–2015 risk register identified internal and external challenges: inefficient internal processes (e.g. recruitment, procurement), insufficient funding for staff and to run operations, and lack of efficient collaboration internally and with external partners and processes. It also mentioned the lack of technical expertise to perform the work properly and the low staff productivity and morale linked to career perspectives in WHO. On the funding side, efficient resource mobilization has led to improved but not yet adequate funding for staff and activities in some of the major offices (Regional Offices for Africa and the Americas and headquarters). Particular efforts have been made to strengthen partnerships with relevant headquarters departments and with external partners (United Nations, civil society, collaborating centres). Four new NGOs have established official relations with WHO on nutrition (International Baby Food Action Network, Action Contre La Faim (ACF), MI, World Cancer Research Fund); four new collaborating centres have been established (Food and Nutrition Department, National Institute of Health, Lisbon, Portugal; Division of Nutritional Sciences, Cornell University, Ithaca, United States of America; Unit for International Collaboration on Nutrition and Physical Activity, National Institute of Health and Nutrition, Tokyo; Department of Nutritional Sciences, University of Toronto, Canada).


Gender, equity and human rights, and social determinants of health

In regional and country offices, it is now almost standard procedure for data from DHIS2 and surveys to be systematically disaggregated by sex and age for targeting the most affected groups (women and children). A concrete example from the Regional Office for Africa The ANI project took social determinants and gender as major issues during planning and implementation phases. For example, the scaling up of nutrition interventions targeted women and adolescent girls in addition to children aged under 5 years. In Ethiopia, Rwanda, Uganda, United Republic of Tanzania and Zimbabwe baseline surveys specifically looked into social determinants in relation to malnutrition, investigating, inter alia, caregivers’ perceptions and knowledge that might give rise to gender biases in infant and young child feeding and care. Results of the analysis were used to develop social and behaviour change communication strategies and approaches for community-based maternal and infant feeding promotion, now being implemented in Ethiopia, Uganda and United Republic of Tanzania.

Output 2.5.2 Norms and standards on maternal, infant and young child nutrition, population dietary goals, and breastfeeding updated, and policy options for effective nutrition actions for stunting, wasting and anaemia developed

Output indicator

Baseline

Target

Achieved value

Number of countries adopting, where appropriate, guidelines on effective nutrition actions for stunting, wasting and anaemia

42 50 TBC

Overview of achievements and challenges

WHO has developed and published evidence-informed guidelines to support public health strategies in several areas related to nutrition interventions and healthy diets. These include fortification of food-grade salt with iodine for the prevention and control of iodine deficiency disorders; recommendations for optimal serum and red blood cell folate concentrations in women of reproductive age for prevention of neural tube defects; the role of delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes; nutritional care of children and adults with Ebola virus disease in treatment centres; and the updated guidelines on sugar intake for adults and children. WHO’s evidence-informed guidelines are available online and through the WHO e-Library of Evidence for Nutrition Actions (eLENA) portal. Currently eLENA contains 100 nutrition interventions, and the eLENA website has been viewed by more than 1.5 million users since its launch in 2011. WHO developed a Guiding principles and framework manual to establish nutrient profiling models. As part of the Secretariat of the Codex Committee on Nutrition and Food for Special Dietary Uses and the Codex Committee on Food Labelling, WHO has provided scientific advice, incorporating NCD concerns as part of implementing the Global Action Plan on NCDs 2013–2020, and has ensured policy coherence between the work of the Codex bodies (in particular the Codex Committee on Nutrition and Food for Special Dietary Uses, the Codex Committee on Food Labelling, the Codex Alimentarius Commission and the Executive Committee of the Codex Alimentarius Commission) and WHO guidelines and policy guidance. WHO has developed policy briefs, linked to each of the global targets, to guide national and local policy-makers on what actions should be taken at scale in order to achieve the global targets in 2025 to improve maternal, infant and young child nutrition. The policy briefs consolidate the evidence around which interventions and areas of investment need to be scaled up, and guide decision-makers on what actions need to be taken in order to achieve them. The WHO recommended actions to scale up effective priority interventions for achieving the six World Health Assembly targets should include both nutrition-specific and nutrition-sensitive investments at the policy, health system and community levels, using an intersectoral approach.


In the African Region: Fourteen countries received technical support to adopt, adapt and implement WHO guidelines and guidance in various focus areas, including stunting reduction, management of severe malnutrition, anaemia control, healthy growth promotion, infant and young child feeding counselling, and protection and promotion of breastfeeding. WHO is also conducting advocacy for healthy diets, an area that requires accelerated efforts to stall the rapidly growing problem of obesity and diet-related NCDs in the region. In the Eastern Mediterranean Region: Actions were undertaken to address diet-related NCD risk factors, such as salt, sugar and fat, through the promotion of a healthy diet. A regional roadmap has been developed and adapted for use at the country level in Morocco, Somalia and Sudan. A nutrient profiling model has been developed and is being tested in seven countries of the Region. Countries in conflict situations have expanded nutrition stabilization centres for treatment of severe and complex cases of malnutrition, notably Afghanistan, Djibouti, Iraq, Pakistan, Sudan, Syria and Yemen. Supplementation and food fortification with essential micronutrients is now done in almost all countries of the Region. Technical support and capacity-building was provided to Member States in the following areas: growth monitoring; food-based dietary guidelines; obesity prevention and control; and promotion of a healthy diet. In the European Region: The Regional Office has been engaging with Member States via the WHO Europe Action Networks, notably in the areas of food marketing to children and salt reduction, and has been providing innovative technical advice to Member States in the full range of policy areas, including recent work on nutrient profile models for the purposes of restrictions on food marketing to children, price policies for the promotion of healthy diets and the trans-European elimination of trans fats. The region has published a new European nutrient profiling model for the control of marketing of foods to children, a guide to eliminate trans fatty acids, and a manual to implement price policies at country level in order to achieve healthier diets. Despite the strong support from the public health community, researchers and civil society, it is challenging for Member States to adopt and integrate this guidance nationally, given the pressure exerted by certain stakeholders. In the South-East Asia Region: Norms and standards on maternal, infant and young child nutrition, population dietary goals, and breastfeeding have been updated, and policy options for effective nutrition actions developed. Technical support has been provided for the development of several technical guidelines at country level, including the development of food-based dietary guidelines (now available in six Member States), the infant and young child feeding guidelines, and guidelines on management of severe acute malnutrition. The Regional Office also assisted in developing capacity for reduction of salt intake and assessing salt iodization, promoting scaling up of micronutrient deficiency prevention programmes on childhood obesity, and restricting the marketing of foods and non-alcoholic beverages to children. In the Western Pacific Region: Policy dialogues on the WHO sugars guidelines were initiated initially in Mongolia, which is in the process of scaling up action to reduce sugar consumption. Support has been provided in the Cook Islands, Fiji, Kiribati, Samoa, Solomon Islands, Tonga and Tuvalu to finalize food regulations, including labelling requirements and standards for food fortification (in Mongolia, Solomon Islands, and Viet Nam). Continuous support was provided to Mongolia to develop regulations for front-of-pack labelling on processed foods. National workshops were held in several countries, including Cambodia, China, Lao People’s Democratic Republic, Mongolia, the Philippines, Samoa and Viet Nam to disseminate recently updated nutrition-related guidelines. Technical support was provided to countries on updated guidelines and online tools developed by HQ (including GINA and eLENA).


Qualitative research was conducted in two areas, one on the consumption of sugary drinks in schools and one on the understanding of health professionals, including medical professionals, midwives and nurses, on conflict of interest. The research also explored experiences with conflict of interest as well as these groups’ recommendations to avoid and manage conflict of interest while practising their profession, especially in the area of nutrition for infants and young children. Three countries drafted roadmaps on childhood obesity prevention (Mongolia, the Philippines and Viet Nam). A bi-regional meeting (South-East Asia Region and Western Pacific Region) was held on restricting marketing of foods and non-alcoholic beverages to children, to discuss progress on implementing the WHO set of recommendations on marketing and prioritize action for the coming biennium. Of the 12 countries that participated, 7 were in the preparation phase of the policy development cycle, while 5 were in the enactment phase. A draft region-specific nutrient profiling model was tested to support implementation of the WHO set of recommendations. In the Region of the Americas: New legislation on the International Code of Marketing of Breast-milk Substitutes was passed in El Salvador and Honduras, and Bolivia and Brazil strengthened existing legislation. Mexico issued a decree prohibiting the donation of infant formulas to health care facilities, and Chile extended maternity protection to six months. In collaboration with UNICEF and the International Baby Food Action Network, PAHO conducted a training course on developing code legislation with the participation of lawyers and nutritionists from 10 Latin American countries. A report was developed to provide a current assessment of the Baby-Friendly Hospital Initiative in Latin America and the Caribbean. Implementation of the Baby-Friendly Hospital Initiative is lagging behind, though many countries are making new commitments and investments to revitalize it, such as Ecuador. School nutrition programmes are being strengthened throughout the region. Many countries, including Mexico, have new legislation to improve the school nutrition environment, and many Caribbean countries have drafted policies that are currently awaiting cabinet approval. A nutrient profile model, developed to provide guidance for the development of fiscal and regulatory policies, addressed five key nutrients: sodium, total fats, trans fats, saturated fats, sugars and non-caloric sweeteners.

Achievements and challenges in countries In the African Region, substantial progress has been made in several countries: in Ethiopia, Uganda and the United Republic of Tanzania, innovative approaches for improving nutrition have been developed and work is under way to scale up. In Côte d’Ivoire, a formative research tool to support engagement of front-line health workers and caregivers in stunting prevention has been translated into French and adapted for implementation. Results from the research will inform scale-up and can be applied in other countries. Ghana has drafted policy briefs on how to address anaemia, stunting and acute malnutrition at scale. In Rwanda, support was provided to the Rwanda Agriculture Board and Ministry of Health to conduct a national survey to determine the causes of stunting among children aged under 5 years. Implementation tools for the WHO child growth standards were developed and rolled out in Burkina Faso, Chad, Guinea-Bissau, Madagascar and Rwanda. Capacity-building for infant and young child feeding support, updating of guidelines and support to the Baby-Friendly Hospital Initiative was provided in Eritrea, Lesotho, Niger, Rwanda and Zambia. Guidelines on the management of severe acute malnutrition have been updated and trainings have been conducted in Burkina Faso, Kenya, Lesotho, Nigeria, Rwanda and Uganda. A food fortification strategy has been developed in Zimbabwe. The Rwanda Bureau of Standards was supported to develop a national standard for formulated complementary foods. In Côte d’Ivoire, expenditure on nutrition was estimated using the 2011 System of Health Accounts. This provides a foundation to advocate increased investment in nutrition for a country that is committed to scaling up nutrition. The challenge is the availability of resources in the country offices to sustain innovative activities. Many countries have no budget to implement planned activities and do not have adequate means for resource mobilization. In the Eastern Mediterranean Region, the following countries showed progress in implementing the work plan in 2014, with significant outputs: Afghanistan, Egypt, Pakistan, Sudan, Syria and Yemen. Major activities included the implementation of effective nutrition interventions, delivery of services in stable and emergency situations at primary care levels, promotion of optimal infant and young child feeding and healthy diets, management and treatment of severe cases of malnutrition and anaemia, and addressing the double burden of malnutrition.


Many countries included their nutrition interventions in their NCD work plans (Egypt, Iraq, Islamic Republic of Iran, Lebanon and Oman) and carried out the development, adaptation and updating of national guidelines and legislations on nutrition, based on the updated global norms, standards and guidelines (for example food-based dietary guidelines, guidelines on micronutrient supplementation and fortification, and draft legislation on marketing breast-milk substitutes). Countries promoted healthy diets (including salt, fat and sugar reduction) through multisectoral coordination and joint programming. Implementation of the nutrition work plans in Libya and Yemen are at risk due to the ongoing security situation and internal conflict. The lack of ministry of health staff with adequate training in the areas of growth monitoring and nutrition surveillance was another challenge in most countries. In the European Region, the revision of nutrition policies has been undertaken in several countries with WHO support. Price policies and nutrient profiling have been implemented. Progress has been seen in breastfeeding, complementary feeding, salt reduction and elimination of trans fats. In Turkey, support has been provided to the evaluation of nutritional status and the provision of nutrition services for Syrian refugees in collaboration with UNICEF. In the South-East Asia Region, Member States have addressed stunting in children and anaemia in children and women, implementing WHO guidelines on stunting, wasting and breastfeeding. In the Western Pacific Region, technical support was provided to Pacific Island countries on front-of-pack labelling (Fiji); developing regulations on marketing of foods and non-alcoholic beverages to children (Cook Islands and Kiribati); and finalizing the regulations on food safety and nutrition in schools in the Lao People’s Democratic Republic. Ongoing support is provided to the Lao People’s Democratic Republic to implement the weekly iron folic acid supplementation programme. Training of health professionals is supported in the Lao People’s Democratic Republic and Tonga and will commence in Mongolia. WHO growth chart standards have been adapted in the Lao People’s Democratic Republic. Challenges include weak health systems, lack of capacity of the workforce to deliver nutrition services, policy incoherence in nutrition, and industry interference in policy development and implementation.

Achievements and challenges at regional and global levels

Guideline development continues to be a priority in headquarters. Guidelines have been published on delayed umbilical cord clamping for improved maternal and child outcomes; salt iodization to prevent iodine deficiency disorders; and nutritional care of children and adults with Ebola virus disease. Dietary guidelines for sugars have also been updated. Guidance work has been developed on biomarkers of iron status and iron deficiency and inflammatory markers for interpreting biomarkers of micronutrient status. The Regional Office for Africa has focused on stunting reduction and has strengthened collaboration with other United Nations agencies (particularly UNICEF) and with NGOs to jointly support country activities in line with WHO guidelines. The Regional Office for the Eastern Mediterranean has provided support to translate global and regional guidance into effective interventions to promote nutrition and to implement effective nutrition actions in stable and emergency situations. A regional nutrient profiling model has been developed, as well as a regional policy statement and action plan on the International Code of Marketing of Breast-milk Substitutes and salt and fat reduction strategies. The Regional Office has provided technical support to countries requiring additional capacities in special areas, such as legislation, standards and specifications on food labelling; fortification of food with micronutrients; management of severe acute malnutrition; the International Code of Marketing of Breast-milk Substitutes; and food-based dietary guidelines. The lack of availability of nutrition data and indicators is a challenge, as well as the inadequate country capacity to perform data collection and analysis. These deficiencies need to be rectified for more effective nutrition surveillance, policy-making and accountability. National health systems should integrate nutrition while providing access for all to integrated health services through a continuum-of-care approach, including health promotion and disease prevention, treatment and rehabilitation, and contribute to reducing inequalities through addressing specific nutrition-related needs and vulnerabilities of different population groups. The Regional Office for Europe developed a report on trans fats. A paper on breastfeeding and complementary feeding has been prepared and maternal nutrition guidelines are being updated.


The Regional Office for South-East Asia has organized a regional meeting to disseminate nutrition guidelines and recommendations, with a focus on micronutrients. Relevant guidelines and recommendations on micronutrients, stunting and wasting, and breastfeeding have been communicated to Member States. Technical assistance was provided to Member States to scale up infant and young child feeding, and to implement iron supplementation, folate supplementation and fortification of food. Good feeding practices have been promoted as part of the early child development package. A compendium of nutrition guidelines and recommendations is being revised and prepared for dissemination to all Member States. The Regional Office for the Western Pacific supported countries to develop, implement and monitor the International Code of Marketing of Breast-Milk Substitutes (Cambodia, Lao People’s Democratic Republic and Viet Nam). National workshops have been convened in Lao People’s Democratic Republic and Mongolia to disseminate recently updated nutrition-related guidelines. Guidance documents, including on essential nutrition actions, have been translated into Lao and Mongolian, and information on eLENA has been disseminated. Lack of financial resources at regional level poses a real challenge to achieving the expected outcomes.

Risks and assumptions The 2014–2015 risk register identified challenges due to inefficient internal processes (travel approval, processes for expenditures, availability of human resources, availability of funds, internal collaboration, staff productivity linked to career development). A risk common to all offices is the lack of adequate financial and human resources. To mitigate these risks, active resource mobilization and engagement with partner institutions across the three levels of the Organization was put in place, as well as backstopping and coaching from HQ to support country and regional offices. The high competition in the area of nutrition is a risk for WHO leadership. To mitigate this risk, WHO has been deeply engaged in joint initiatives, such as the SUN movement and the Global nutrition report, and has also launched joint initiatives, such as the joint malnutrition estimates with UNICEF and the World Bank. Collaboration with partners (including FAO, UNICEF and GIZ) needs to be pursued more proactively, and regular communication is needed. Competing priorities may lead to lack of attention by Member States to the political processes in nutrition. To mitigate these risks, great attention has been given to the country cooperation strategies and to the Member State discussions at the World Health Assembly and ICN2. HQ is also working with the communication department and is engaging with external partners, such as foundations, civil society, FAO, UNICEF and UNSCN, to promote messaging of nutrition work. Another risk is the inadequate political commitment on multisectoral mechanisms for successful implementation of nutrition-sensitive interventions. Advocacy for multisectoral interventions and setting up comprehensive monitoring and surveillance mechanisms initiatives are needed at the country level. Good coordination and collaboration between relevant institutions within ministries of health is critical to achieving a reduction in all forms of malnutrition, including both undernutrition and overweight and obesity. A risk for many countries, particularly in the Eastern Mediterranean Region, has been political instability. Implementation of activities has to take into consideration the different stages of security situations (including the emergency, development and recovery stages). The successful delivery of outputs relies on the commitment by all Member States to review their plans. This depends on country-level advocacy; effective synergy with United Nations partners through REACH, UNSCN and the SUN movement; availability and commitment of partners and stakeholders, such as the European Union; and availability of human resources. This assumption still holds in the majority of countries.

Gender, equity and human rights, and social determinants of health In all major offices, gender, equity and human rights-based approaches have been considered in nutrition programmes, and there has been a special focus on gender issues and human rights during the planning, implementation and monitoring of activities.


Vulnerable groups, including women, adolescent girls and children, have been especially considered in order to ensure equity and human rights in all targeted areas and programmes, as per Article 25 of the Universal Declaration of Human Rights and Article 11 of the International Covenant on Economic, Social and Cultural Rights. A specific example comes from the Regional Office for the Western Pacific, where weekly iron folic acid supplementation in the Lao People’s Democratic Republic was particularly designed to target the vulnerable. Also, in China, a report on the nutrition situation of left-behind children was developed, including recommendations to improve the nutrition situation of children under 5 years of age in Shaanxi Province.

III. SUMMARY OF FINANCIAL IMPLEMENTATION FOR THE PROGRAMME AREA

2014-2015 (US$ 000) AFRO AMRO SEARO EURO EMRO WPRO HQ Total

WHA approved budget 3,900 2,800 3,000 2,000 3,000 3,100 22,200 40,000

Funds Available (as at 31 Dec 2015)

Flexible Funds 1,843 2,320 1,369 774 1,355 1,524 8,278 17,463

Voluntary Contributions Specified 12,557 588 45 821 1,289 825 9,202 26,148

Total 14,400 2,908 1,414 1,595 2,644 2,349 17,480 43,611

Funds available as a % of budget 369% 104% 47% 80% 88% 76% 79% 109%

Staff costs 2,664 802 697 635 609 1,006 10,636 17,049

Activity costs 9,894 1,992 689 808 2,296 1,309 5,310 22,298

Total expenditure 12,558 2,794 1,386 1,443 2,905 2,315 15,946 39,347

Expenditure as a % of approved budget 322% 100% 46% 72% 97% 75% 72% 98%

Expenditure as a % of funds available 87% 96% 98% 90% 110% 99% 91% 90%

Staff expenditure by Major Office 16% 5% 4% 4% 4% 6% 62% 100%

Major financial implementation issues that affected programme delivery Overall, funds were available to cover the 2014–2015 budget and the total amount of funds received was US$ 43.6 million, i.e. 109% of the approved budget. However, the distribution of available funds among the major offices was very uneven. The quota from specified contributions also accounted for a variable proportion of the available funds – from 3% in the Regional Office for South-East Asia to 87% in the Regional Office for Africa. This was due to the contribution of a major donor (DFATD) that was focused on the African Region, suggesting that the potential for obtaining donor funds in some regions is not adequately exploited. The use of funds was satisfactory, with expenditure at 90% of available funding. On average, 43% of the available funds were spent on human resources, with a range of 21–67%, the lowest proportion in the Regional Office for Africa and the highest in headquarters. As the majority of available funds was from specified contributions, it was a challenge to deal with areas of work that related to WHO’s institutional functions and that would have to rely on flexible funds, such as the interagency work, the Codex Alimentarius work and the policy advice to countries. In the Regional Office for South-East Asia staff recruitment delays led to a temporarily reduced operational and fund-raising capacity.


IV. LESSONS LEARNED AND OUTLOOK FOR 2016–2017

Lessons learned in 2014–2015 WHO will continue to collaborate with United Nations system agencies and further reach out to other partners to advocate the use of the six World Health Assembly global nutrition targets as instruments for further alignment by all actors in nutrition. The continued shortage of nutrition staff and lack of resources is adapted to by (a) establishing partnerships with added value and no conflict of interest for WHO; and (b) ensuring alignment and joint programming with United Nations partner agencies. Whereas nutrition continues to receive attention worldwide, WHO needs to be prepared to be able to respond to an increase in requests for support by Member States. Whereas, at the same time, the global nutrition architecture is complex, WHO needs to clearly define its niche and strengths for nutrition and market these effectively.

Impediments due to any outbreak and emergency response, including the response to the Ebola crisis Planned work in four West African countries was directly impacted by the Ebola crisis, and conflicts in northern Mali and Nigeria have impeded the implementation of activities in affected areas. Reconstructing health systems and recovery of basic livelihoods is going to be a priority when the Ebola crisis is brought under control. Only then is normal programmatic activity likely to restart.

Outlook for 2016–2017: planning for the Sustainable Development Goals (SDGs) The SDGs provide not only unique and unprecedented opportunities for countries to act multisectorally but also provide also an important impetus to advance nutrition globally. As the SDGs are universal in nature, all countries will need to translate the SDGs into national targets, priority setting and action. This new way of thinking holistically and acting sustainably and across sectors needs to also be practised by WHO: thinking and acting across departments for the 2030 Agenda in its whole, not only narrowly for SDG 3. If and when the Decade of Action on Nutrition (2016–2025) will be endorsed by the United Nations General Assembly, as recommended in paragraph 17 of the ICN2 Rome Declaration, it will be an additional assignment for WHO to provide leadership, in collaboration with FAO, and will not only bring all nutrition-related commitments, targets, initiatives and platforms together under one roof (that of the United Nations General Assembly) but will also support Member States to make additional ambitious and SMART nutrition commitments and regularly report to the intergovernmental bodies, including the World Health Assembly, the FAO Council and the Economic and Social Council. It will therefore be of utmost importance for WHO to demonstrate added value, cohesion, institutional commitment and vertical and horizontal coherence. The development of the new WHO nutrition strategy is therefore timely and will catalyse these features.

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