SOMALI NUTRITION STRATEGY

2011 – 2013

Towards the

Millennium Development Goals

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© World Health Organization/UNICEF/WFP/FAO/FSNAU 2010All rights reserved. The designation employed and the presentation of the material in this report including tables and maps, do not imply the expression of any opinion whatsoever on the part of the World Health Organization, UNICEF, WFP and FAO/FSNAU concerning the legal status of any country, territory, city or area or of authorities or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent border lines for which there may not yet be full agreement. The mention of specific companies or suppliers or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization, UNICEF, WFP or FAO/FSNAU in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization, UNICEF, WFP and FAO/FSNAU do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.

This publication may be reproduced free of charge in any format or medium, provided that it is reproduced accurately, that the original contributors are given due credit, and that it is not used in a misleading context.

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ForewordGood nutrition is one of the key foundations for the development of a healthy, productive population. Well nourished people are less likely to become ill or die, and are more productive and better able to learn. Achieving good nutrition, particularly among women and children, is associated with important short and long term health, educational and economic benefits.

Situational analysis of data from Somalia over the last decade indicates that undernutrition is a significant and enduring public health problem and a major factor in the failure to meet MDGs on hunger, child health, maternal mortality, gender equality and education. Rates of acute and chronic malnutrition have remained persistently high throughout Somaliland, Puntland and South Central Somalia, with some variation by zone and livelihood system.

Ongoing conflict, displacement, breakdown in social and public services coupled with recurrent droughts and flooding have significantly affected food security and livelihoods and therefore nutritional status. However, there is a growing body of evidence that other underlying causes also contribute significantly to high and persistent undernutrition. These factors include: chronic poor dietary diversity, inadequate infant, young child and maternal feeding practices, poor hygiene practices, water and sanitation, poor health seeking behaviours and low access to quality health services and education and gender inequalities. The persistence of undernutrition, even in years of relative stability and good harvest, adds further weight to the importance of these multiple underlying causes which by their nature cut across traditional sectors. With increasing understanding of the causes and their complexity, the challenge now is to strengthen efforts to address them through an integrated multi-agency, multi-sector response.

The objective of the work carried out by authorities, donors, UN agencies and local and international implementing partners was to develop a joint framework for action to improve the nutritional status of the Somali population, thereby contributing to an overall improvement in their survival, growth and development.

The activities detailed in this strategy aim to respond to the challenges raised above and focus interventions to achieve 6 priority outcomes that will lead to accomplishment of the overall goal: i) improved provision of quality services for the management of acute malnutrition; ii) sustained quality nutritional surveillance and analysis of nutrition information to inform appropriate and rapid responses; iii) improved knowledge, attitudes and practices regarding infant, young child and maternal nutrition; iv) improved availability, accessibility and coverage of micronutrients and de-worming; v) increased redress of underlying negative practices through awareness and commitment to effective action across other sectors and finally vi) improved capacity and means in country to make effective nutrition responses.

The development of the strategy has been based on a number of guiding principles. Primarily the strategy recognises the basic human right to adequate food and health and freedom from malnutrition and disease. It respects the humanitarian principle of ‘do no harm’ such that its’ implementation should not exacerbate or worsen the situation.

A key guiding principle is recognition of the specific context and challenges of implementation in Somaliland, Puntland and South Central Somalia. The multi-sectoral responses identified are based on an understanding of the specific political, economic, social and cultural factors that determine nutritional status. The interventions detailed in the action plan reflect universally accepted best practice and evidence-based programming. However, not all interventions proven effective in addressing malnutrition (The Lancet series on Maternal and Child Undernutrition) are

iv feasible in the Somali context where the volatile environment, low access, weak infrastructure and legislative framework are major constraints. Therefore, the strategy aims to prioritise and adapt what is proven effective, with what is viable in the context.

Finally, mindful of the importance of using limited resources to greatest efficiency, the strategy focuses on investing in the areas most likely to achieve maximum impact. As such, interventions are targeted at pregnant mothers and children up to the age of two years as the critical window of opportunity for reducing undernutrition and its adverse effects. (Lancet series on Maternal and Child Undernutrition). Furthermore, many of the interventions identified in this strategy correspond to those acknowledged by the Copenhagen Consensus 2008 as the most cost effective interventions for global development.

This strategy has been developed through strong interagency collaboration, with input and endorsement from Somali authorities. It is hoped the strength of this collaboration prevails throughout the implementation phase, in pursuit of a common overall goal to improve the growth, survival and development of the Somali people. The strategy provides the way forward for stronger partnerships within the nutrition sector and between nutrition and other sectors and ministries for coherent action to achieve this shared goal through improving the nutritional status of the population.

Mark Bowden UN Resident and Humanitarian Coordinator for Somalia

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This Somali Nutrition Strategy has been developed in response to increasing evidence and awareness that the persistently high rates of malnutrition in Somalia are related to multiple underlying causes that need to be addressed through a more holistic and longer term approach.

The process of developing the strategy has been a consultative. Initially, a task force of technical representatives from key UN agencies and local and international NGOs was formed to work on a draft. A results based, action orientated approach was adopted, using the logical framework to identify and define the overall goal, outcomes, outputs and activities of the strategic plan. The outcomes identified reflect the priorities identified in the situational analysis and analysis of the strengths, weakness, opportunities and threats of current nutrition programming.

The draft prepared by the technical interagency task force was then shared with nutrition and other relevant clusters and sector working groups, and the UN County Team at Nairobi level. A key stage of the process was sharing the draft with Somaliland, Puntland and TFG authorities and local actors for their input and obtaining their endorsement. Thus the final document represents a consensus on the combined inputs of all relevant stakeholders.

Preface

vii AcknowledgementsAs outlined above, the process of developing this strategy has been a collaborative one between UN agencies, local and international NGOs, line ministries of Somaliland, Puntland and TFG authorities. We would like to acknowledge the contributions of staff from all these various agencies.

In particular, special thanks go to members of the technical Task Force for their experience, knowledge and time devoted to developing the strategy:

Dr Anthony Abura World Vision International Fitsum Assefa Nutrition Project Co-ordinator, UNICEF SomaliaSuzanne Brinkman Nutrition Coordinator, Save the Children UK Anne Bush Consultant Public Health Nutritionist, WHO SomaliaAhono Busili Deputy Nutrition Technical Manager, UNFAO/FSNAUAbdullahi Mohamed Diriye Development Initiative Access Link (DIAL)Erin McCloskey Nutrition Advisor, Somalia, Concern WorldwideAbdi Moge Mohammed Somalia Aid Foundations (SAF)Grainne Moloney Nutrition Technical Manager, UNFAO/FSNAUAnne-Sophie Porche Nutrition Cluster Coordinator, UNICEF SSCMarc-Andre Prost Nutrition Officer, WFP SomaliaUnni Silkoset Nutrition Specialist, UNICEF Somalia CSZKeith Ursel Head of Programme, WFP Somalia

Thanks also go to other key contributors:Fatuma Abdirahman CTC Project Manager Oxfam NovibAusten Davis Chief, Accelerated Child Survival and Development

Programme, UNICEF Somalia Dr Marthe M. Everard Representative WHO Somalia Peter Hailey Regional Nutrition Specialist, UNICEF EASROAbdirizakov Osman Nutrition Officer, UNICEF Somalia CSZ Dr Humayan Rizwan Technical Officer (PHC) WHO Somalia Osborne Sibande Acting Nutrition Officer WFP SomaliaRandhir Singh Relief InternationalMarijka van Klinken Nutrition Project Officer (Intern) UNFAO/FSNAU

Members of the IASC Nutrition Cluster Members of IASC WASH, health, food aid and agriculture/livelihoods clusters

Somaliland contributorsAbdillah Seleman Abdi MoADr Mohamed Saleban Adan MoADr. Hassan Abdillahi Ahemd MoH/LFoosiya Ahmed MoH/LAmina Barkahod MoH/LRahma Mohamed Cabdi MoH/LAbdirahman Deria AGAADAbdi Dahir Elmi WHOMohamed Sulyman Elmi MoCFatuma Ali Farah MoH/L

Mumtoos Dahir Farah SIAMAFatuma Ali Farax MoH/LSadik MohamoudGahyer Muslim Aid UKHassan Haileh MoH/LAhmed Hassan ANPPCANDr.Abdi Hussein MoH/LDr. Mohamed Idan MoH/LDr. Faysal Ismail MoH/LDr. Saynab Mohamed Ismail MoH/L

viii Dr. Ahmed Mohamed Jama MoH/LTheresa Loro WFPKadair Abdiillah M MerlinJane Maina WVINeura Ibrahim Mohamed MoH/LDr. Khadar Mohamed MoH/LKoos Mohamed WFPZivai Murira UNICEFGeorge Mutwiri Medair

Dr. Mohamed Osman Nur MoH/LMohamed Sheikh UNICEFDr. Ali Shiekh MoH/LNorman Sitali MSF HollandMohamed Osman Yabe MoH/LDr. Abdi Kin Ying WHOZainab Maxed Yusuf MoFAsia Osman WHO

Puntland contributorsAbi Abdallah Warsame, Minister of HealthHamdi .Y. Abdullahi WFPMohamud Abdullahi WFPHamdi Abdullahi Ali SCUKJama Mohamed Daar SCUKAbdikarim Husen Duale FSNAUMohamed Ahmed Duale SOMDA Said Abdullahi Duale MoHAli Mohamd Esese OIPA/rashid Gabobe Esse MoHKhadro Mohamud Esse MoHAbdirahman Omar Fahad MoHAhmed Abdirahman Fahiye MoHMohamed Ali Fantole SDRADr Abdirazak Hirsi MoHMohamed Jama Hirsi MoHAbdinasir Sheikh Ibrahim MoHBashir Ali Ismail GDAHodan Mire Ismail UNICEF

Mukhtar Mohamed Jama MoHNaimo Mukhtar Moalim RPSAamina Abdi Mohamed Ein MCHNAnisa Ali Mohamed MoHDr Dahir Aadan Mohamed WHOFardowsa Ahmed Mohamed MoHMohamed Hared Mohamed SDROSaid A/qadir Mohamed Muslim AidSirad Aadan Mohamed SRCSAli Hassan Mohemed WHOMohamed Abduqadir Mulah MoHZivai Murira UNICEFAbdirahman Yusuf Muse UNICEFMohamed Abdulkadir Nor BIOFITHawa Yusuf Osman MoHLayla Said LQCDr Maymun Farah Samatar PMWDOHassan Abdi Shire MoHSaid Mohamed Warabe MoHMohamed Said Yusuf MoPIC

TFG contributorsDr Adan Haji Ibrahim Daud: Minister of HealthDr Abdi Awad: advisor to TFG MoH Dr Lul Mohamed Mohamed: Paediatrician in Benadir Hospital Abdinasir Hagi Mohamed: Director of Disaster and Risk Management Dept, Ministry of Humanitarian Affairs

Other contributorsDr Anna Verster, Nutrition Advisor to WHO and Senior Advisor on Food Fortification, who undertook preliminary work on developing the strategy

Anne Bush, Consultant Public Health Nutritionist WHO/UNICEF, who led the multi-agency task force and compiled the strategy document.

Thanks also go to FSNAU/FAO for their assistance in the design of the document and to WFP Somalia office for funding the printing of the final document. Also to WHO and UNICEF Somalia who contributed to the funding of the process, including the consultancy costs.

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AcronymsAYCS Accelerated Young Child SurvivalBCC Behaviour Change CommunicationCAP Consolidated Appeal ProcessCBI Community Based InitiativesCHD Child Health DayCMAM Community-based Management of Acute MalnutritionCTC Community-based Therapeutic CareEPHS Essential Package of Health ServicesFAO Food and Agriculture OrganisationFEWSNET Famine Early Warning Systems NetworkFSNAU Food Security and Analysis Unit – Somalia GAM Global Acute MalnutritionGAVI Global Alliance for Vaccines and ImmunisationHAZ Height for Age Z-scoreHMIS Health Management Information SystemHSS Health System StrengtheningIBFAN International Baby Food Action NetworkIDP Internally Displaced PopulationINGO International Non Governmental OrganisationIYCF Infant Young Child FeedingKAPS Knowledge, Attitudes and Practices Survey LNGO Local Non Governmental OrganisationMAM Management of Acute MalnutritionMCH Maternal Child Health MDG Millennium Development GoalsMICS Multi-Indicator Cluster SurveyMI Micronutrient InitiativesMoH Ministry of HealthNEZ North East ZoneNGO Non Governmental OrganisationNWZ North West ZoneOTP Out patient Therapeutic feeding ProgrammeRDP Reconstruction and Development Plan SAM Severe Acute Malnutrition SC Stabilisation CentreSFP Supplementary Feeding ProgrammeSCZ South Central ZoneUNICEF United Nations Children’s FundUNTP United Nations Transition PlanWABA World Alliance for Breast Feeding ActionWASH Water and Sanitation HygieneWFP World Food ProgrammeWHO World Health OrganisationWHZ Weight for Height Z-Score

x Table of ContentsForeword iiiPreface viAcknowledgements viiAcronyms ixExecutive Summary 1

1. Background 31.1 Nutrition situation 31.2 Determinants of malnutrition 41.3 Nutrition interventions 5

2. Justification, Scope and Guiding Principles 82.1 Justification 8

2.2 Scope 82.3 Guiding principles 8

3. Goals, outcomes, outputs 104. Implementation 13

4.1 Opportunities 134.2 Partnerships 144.3 Zonal differences 154.4 Formative research 164.5 Technical support 164.6 Behaviour Change Communication 16

5. Monitoring 17

AnnexesAnnex 1. Logical framework - Results based matrix 19Annex 2. Situational analysis 42Annex 3. Justification of outcomes and key approaches adopted in this strategy 60 Annex 4. Proven effective interventions identified by Lancet series on Maternal and Child Undernutrition 65Annex 5. Copenhagen Consensus 2008 66Annex 6. How malnutrition affects achievement of MDGS 67 Key References 68

List of Figures Figure 1. Seasonal trends in national median rates of acute malnutrition 2001-2009 3Figure 2. Annual national median stunting rates 2001-2009 4Figure 3. Median rates of wasting, stunting and underweight by Zone 2001-2008 4Figure 4. Prevalence of anaemia and vitamin A deficiency amongst women and children 2009 4Figure 5. Prevalence of some key determinants of malnutrition in Somalia 2009 5Figure 6. Trends in wasting, stunting and underweight by livelihood group, 2001-2008 44Figure 7. Malnutrition rates by zone 2009, according to National Micronutrient and Anthropometric Nutrition Survey, Somalia 2009 45Figure 8. UNICEF Conceptual model of causes of malnutrition 47Figure 9. Breast feeding initiation 49Figure 10. Age Specific fertility rates by urban-rural residence, Somalia 2006 50Figure 11. Immunisation coverage among children under five years, 2009 51

MapMap 1. Map of current nutrition situation and interventions as of 18th March 2010 7

List of TablesTable 1. SWOT analysis of current nutrition interventions in Somalia 56Table 2. Existing programmes presenting opportunities for the integration and strengthening of nutrition activities 57

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Executive SummaryMalnutrition in Somalia is a huge public health problem, negatively affecting growth, development and survival of the population. Situational analysis shows a long term nutrition crisis characterised by persistently high rates of acute and chronic malnutrition throughout the country with some variation by zone and livelihood system. This situation reflects nearly two decades of armed conflict and insecurity, with breakdown in social and public services coupled with recurrent droughts and flooding seriously affecting food security and livelihoods. In response to the alarming rates of acute malnutrition, nutrition programming coordinated by the Nutrition Cluster, has been primarily focussed on the immediate needs of saving lives through the management of acute malnutrition, based on seasonal assessments of food security and nutrition surveillance data primarily by FSNAU.

However, surveillance data shows that even in years of improved food production and relative stability, rates of acute and chronic malnutrition remain high in certain regions indicating other underlying causes play a significant role. Evidence shows that sub-optimal infant, young child and maternal feeding and care practices, low dietary diversity, poor hygiene, water and sanitation, high morbidity coupled with inadequate access to health care are key determinants of the problem. To address these multi-factorial and overlapping causes, a holistic package of interventions with multi-sector collaboration is required. This strategy has been developed via a consultative approach between UN agencies, local and international NGOs and the national and regional health authorities to provide an agreed upon framework for action to meet this need for a shift to a more holistic approach.

The results-based strategy provides a detailed action plan to guide prioritisation of interventions in face of limited resources, project implementation and resource mobilisation. Based on the situational analysis, review of best practices and proven effective interventions feasible in the challenging context of Somalia, the following goal and outcomes for the strategy have been established.

Overall of the strategy is: To contribute to improved survival and development of Somali people through enhanced nutritional status.

This will be accomplished through the achievement of the following outcomes: Outcome 1: Improved access to and utilisation of quality services for the management of

malnutrition in women and childrenOutcome 2: Sustained availability of timely and quality nutrition information and operational

research into effective responses to the causes of undernutrition Outcome 3: Increased appropriate knowledge, attitudes and practices regarding infant, young

child and maternal nutritionOutcome 4: Improved availability and coverage of micronutrients and de-worming interventions

to the population Outcome 5: Improved mainstreaming of nutrition as a key component of health and other

relevant sectors Outcome 6: Improved capacity and means in country to deliver essential nutrition services

The outcomes will be achieved by conducting defined activities that will produce key outputs. Implementation of the strategy will be guided by the overarching principle of improving partnerships between all stakeholders – local and national authorities, donors, UN agencies, local and international NGOS, local community and the private sector – and increased collaboration

2 between sectors. While the main entry point will be through the strengthening of existing structures and services, the strategy also explores new avenues for the provision of services, for example, the fortification of cereal flours.

Due to constraints to rapid scale up of interventions (restrictions in access, logistic, human and financial resources) a phased approach has been adopted. Activities for the first year (phase 1) are focused on the adaption and standardisation of tools, training and strengthening of structures and mechanisms in preparation for delivery of interventions in the subsequent years (Phase 2). The strategy is consistent with the United Nations Transition Plan (UNTP) for Somalia 2008-09 and has been included in the Reconstruction and Development Plan (RDP) for the next three years.

The three year term of the strategy is too short to measure significant changes in nutritional status and mortality as outcome indicators. Instead, the results matrix gives details of the output and outcome (impact) and activity (process) indicators and their source of verification against which effectiveness of the strategy will be measured. The progress made in the implementation of the strategy will be reviewed and updated on an annual basis. The inter-agency review process will be led by the Ministries of Health in collaboration with technical support from the Health Sector Committee and undertaken with all stakeholders including regional line ministries. Annual review will be timed to take place prior to the Consolidated Appeal Process (CAP) so that findings can help inform and identify funding priorities.

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Since the collapse of central government in 1991 and the resulting civil war, there have been many efforts to restore a central government in Somalia without sustained success. In 1991, the North west zone (NWZ) declared the independent state of Somaliland, with its governing administration in the capital Hargesia. The North east Zone (NEZ) declared itself as the autonomous region of Puntland in 1998. Although governed by its administration in its capital Garowe, it pledges to participate in any Somali reconciliation and reconstruction process that should occur. In South Central Somalia political conflict and violence continue to prevail, despite attempts to establish and support a central governing entity.

A detailed situational analysis of the nutrition situation in country, determinants of malnutrition and current nutrition interventions, strengths, weaknesses, opportunities and threats can be found in annex 2. In brief, eighteen years of war and insecurity have had devastating effects on the nutrition and health status of the people of Somalia, which was already precarious even before. The combination of conflict, insecurity, mass displacement, recurrent droughts and flooding and extreme poverty, coupled with very low basic social service coverage, has seriously affected food security and livelihoods and greatly increased vulnerability to disease and malnutrition. The MDG health-related indicators are among the worst in the world. Life expectancy is 45 years. One child in every twelve dies before the age of one year while one child in seven dies before the age of five.

1.1 Nutrition situationRates of acute malnutrition and chronic malnutrition are alarming throughout the country with some variations by zone and livelihood system. The most recent assessment from FSNAU Post Deyr ‘09/10 found a national median global acute malnutrition (WHZ < -2 SD) rate of 16%, severe acute malnutrition (WHZ < -3 SD) rate of 4.2%, based on WHO growth standards (2006). These rates correspond to an estimated 240,0001 children acutely malnourished of which 63,000 children are suffering severe acute malnutrition. Thus one in six children aged 6 to 59 months are acutely malnourished and one in twenty two, severely malnourished. In addition, according to the previous FSNAU seasonal assessment post Gu 2009, 84,000 pregnant and lactating women are estimated to be acutely malnourished.

Preliminary results from FSNAU meta analysis of data from 2001 to 2009 highlight the chronic nature of this alarming situation. The results show that over this period, median rates of global acute malnutrition have remained at Serious (10 to <15%) or Critical (15 to <20%) levels (WHO Classification 2000) throughout (Figure 1), with a national median rate of 16%.

Furthermore, annual national median rates of stunting were above 20% ie at serious level throughout the period 2001 to 2009, according to WHO classification (2000), as shown in figure 2.

1 Figures based on population figures from the UNDP 2005 settlement survey are used as the standard reference for Somalia

BACKGROUND1

0.0%

5.0%

10.0%

15.0%

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25.0%

30.0%

35.0%

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Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr

2001 2002 2003 2004 2005 2006 2007 2008 2009

GAM SAM

Figure 1: Seasonal trends in national median rates acute malnutrition 2001-2009 - Source FSNAU

4 Preliminary results of the meta-analysis also highlight how the situation has been consistently worse in South Central Somalia than Puntland or Somaliland. In South Central Somalia, median rates of stunting were found to be 29.7% and wasting 18%; this compares to 20% stunting and 17% wasting for Puntland and 18% stunting and 13% wasting for Somaliland (see figure 3). This reflects the devastating effect of chronic political conflict and insecurity in South Central Somalia in particular.

Rates of malnutrition also vary according to livelihood system. Briefly, preliminary results of the FSNAU meta analysis of data 2001-2008 revealed that riverine and agro-pastoralist groups had the highest median rate of wasting, stunting and underweight suggesting a higher nutritional vulnerability to shocks – floods, drought, displacement, disease outbreak. Rates of malnutrition among the urban population tended to be lower, reflecting better access to a diversified diet and to public services including health.

The recent National Micronutrient and Anthropometric Nutrition survey conducted between March and August 2009 in all three zones, has highlighted micronutrient malnutrition is a significant public health problem throughout Somalia. The prevalence of both nutritional anaemia and vitamin A deficiency among women and children of all age groups was found to be above WHO thresholds for classifying a severe situation in each of the 3 zones (see figure 4).

1.2 Determinants of malnutrition Malnutrition results from a complex set of factors and not one simple cause. The UNICEF conceptual model of causes of malnutrition (page 16) provides a useful framework for the discussion of the causes of malnutrition in Somalia. The volatile political situation and civil unrest have led to a chronic and continuing humanitarian crisis that is at the root of the high prevalence of malnutrition in Somalia. Somalia is also prone to drought and floods. Many of the environmental and man made shocks have been multiple and recurrent, over stretching families’ coping mechanisms resulting in inadequate access to and availability of food at household level.

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Figure 3: Malnutrition rates by Zone in Somalia (2001-2008)

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Figure 4: Prevalence of anaemia and vitamin A deficiency amongst children and women

Source FSNAU data Micronutrient Study

Source: FSNAU 2010

Figure 2: Annual National Median Stunting rates 2001-2009

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5 However, even in years of relative stability and improved food production, the malnutrition rates in some regions of Somalia have been consistently high, pointing to the important role of other underlying causes. These include sub optimal infant, young child and maternal feeding and care practises as documented by the National Micronutrient and Anthropometric Nutrition Survey 2009, KAPS 2007 and MICS 2006 results. Morbidity is high while access to and utilisation of quality health services is limited (KAPS 2007 and MICS 2006). The water and sanitation situation is poor. Feeding, care and hygiene practices are inadequate not only due to lack of public services but also due to cultural practices and beliefs. Figure 5 summarises data from the micronutrient survey indicating the low coverage of some of these key determinants. Each is discussed in more detail in the situational analysis attached (annex 2).

1.3 Nutrition interventionsDue to inadequate governance structures in parts of Somalia, nutrition response programming is mainly undertaken by UN, international and national NGOs. Nutrition interventions are primarily focussed on responding to alarming rates of acute malnutrition throughout the country. Food security and nutrition surveillance and early warning reports (FSNAU, FEWSNET, WFP) are key activities providing quality information and analysis for the targeting of appropriate and timely responses to changing needs in country. Outpatient therapeutic feeding programmes (OTPs) for the management of severe acute malnutrition are being implemented across Somalia by international NGOs and UNICEF in partnership with local NGOs, according to operational guidelines that take into account the challenging environment, reduced supervision and limited monitoring.

Targeted supplementary feeding programmes (SFPs) for the management of moderately malnourished under-fives and pregnant and lactating women are being implemented by WFP through around 40 local and international NGOs. The current caseload is around 70,000 beneficiaries, of whom approximately 80% are under-fives and 20% pregnant and lactating women. Map 1 shows the current nutrition situation and interventions based on latest reports.

Activities for the prevention of moderate acute malnutrition include the provision of fortified supplementary food by WFP to all children under-two and pregnant and lactating women, through UNICEF-supported MCH clinics at selected sites in Puntland and Somaliland. Currently 35 clinics are supported. In addition, in 2009, UNICEF launched a new initiative for the prevention of malnutrition, targeting 100,000 children aged 6-36 months with blanket distribution of ready-to-use food (Plumpy Doz) every two months in areas showing the highest malnutrition rates.

Baidoa MCH, UNICEF Somalia, CK Minihane

0 10 20 30 40 50 60 70 80 90 100

,Increased feeding during diarrhoea 0-59 mths

!Prevalence of diarrhoea 0-59 mths

Access to improved water source

Vitamin A coverage 6-59mths

%Immunisation coverage DPT 6-23 months

6Introduction of solids, semi solids, soft food 6-8mths

"Continued breastfeeding to 24 mths

3Early initiation of breastfeeding (within 1st hour)

#Exclusive breastfeeding upto 6 mths

prevalence %

Figure 5: Prevalence of indicators of some key determinants of malnutrition in Somalia

Source: Micronutrient Survey2009

6 Furthermore WFP is providing food assistance to vulnerable groups through institutional feeding and school feeding to around 90,000 beneficiaries. WFP also provides a general food ration consisting of cereals, CSB, sugar, fortified oil and iodised salt when available, to the rural population affected by the humanitarian crisis, the urban poor and IDPs. In 2009 this food assistance covered around 3 to 3.5 million people a month – almost half the population – on the basis of FSNAU seasonal assessments.

Nutrition interventions delivered through health campaigns include vitamin A distribution, deworming and nutritional screening during bi annual Child Health Days. Furthermore, nutrition interventions are delivered through the 3 levels of the health system – health posts, MCH Clinics and hospitals. Coverage and quality is currently limited due to overall weaknesses of the public health system.

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Map 1: Somalia - Nutrition Treatment Interventions in Somalia as of November 2010

2. JUSTIFICATION, SCOPE & GUIDING PRINCIPLESJUSTIFICATION, SCOPE & GUIDING PRINCIPLES2

2.1 Justification

As described above, Somalia faces multiple challenges - not least conflict, drought, flooding, inadequate and inequitable social and public services and massive population displacement - but persistently high levels of malnutrition are undermining the survival, growth and development of the population. Rates of acute and chronic malnutrition have consistently exceeded emergency thresholds in some areas for more than 10 years now. Due to the scale of the humanitarian situation in Somalia and the alarmingly high rates of acute malnutrition, the vast majority of the nutrition interventions are focussed on the management of acute malnutrition. This remains a key priority to prevent associated excess morbidity and mortality.

However, the situational analysis shows that in some regions rates of chronic and acute malnutrition remain high even outside of times of crisis, with multi factorial underlying causes. These underlying causes include: sub optimal infant, young child and maternal feeding and care practices, poor dietary diversity, inadequate water and sanitation and high morbidity coupled with poor access to and utilisation of health services. These multiple and overlapping determinants of malnutrition in Somalia require a holistic package of interventions delivered through a multi sectoral channels to address the huge public health problem. The range of stakeholders and the variety of approaches and projects with a nutrition goal or outcome mean a coordinated approach is necessary. The response also requires longer term planning, funding and programming. This strategy therefore has been developed to provide an agreed upon framework for action to respond to this need for a shift in approach, whilst continuing to improve the quality of management of acute malnutrition.

2.2 Scope

This strategy provides a tool to support co-ordinated action to improve and expand quality nutrition programming in Somalia in a phased approach over the next three years. It is based on a logical framework and is therefore rooted in actions that if conducted produce results that ultimately mean outcomes are accomplished and the overall development goal is achieved. It is intended as an advocacy document for UN agencies and partners to donors. The results-based approach provides an action plan which guides the prioritisation of interventions in a situation of limited resources, project implementation and capacity building in the relevant areas, and resource mobilisation. It identifies opportunities and existing structures that provide entry points for developing and integrating interventions. It aims to encourage the development of partnerships between all relevant stakeholders and facilitate cross sector initiatives to address the multi-factorial direct and underlying causes of malnutrition, whilst recognising the challenges of implementation in Somalia

As malnutrition is one of the most important constraints to achieving MDGs, these coordinated efforts will assist Somalia in making more meaningful progress towards attaining its MDGs. In particular, those more directly affected by improving malnutrition: goal 1 on reducing hunger, and goals 4 and 5 on the reduction of child and maternal mortality (see Annex 6).

2.3 Guiding Principles

This implementation of this strategy will be guided by the following principles:- Recognition of the basic human right to adequate food and health, for all people to have access to

safe and nutritious diets to be free from malnutrition and related disorders.

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- Recognition of the multiple and overlapping causes of malnutrition that require a longer term, inter-sectoral strategy and that reflect an understanding of the political, economic, social and cultural factors that determine nutritional status

- Recognition of the need to build local capacity and resources to respond and promote local ownership

- Recognition of the context of the specific situation in Somalia where access is limited, using existing services and structures as entry points for enhanced interventions.

- Recognition that the critical window of opportunity for reducing undernutrition and its adverse effects is the period from pregnancy to 24 months of age (Lancet series on Maternal and Child undernutrition). Interventions after 24 months are much less likely to improve nutritional status and do not reverse earlier damage.

- Reflection of universally accepted best practice and evidence based interventions. The Lancet series on Maternal and Child undernutrition provides evidence on interventions that are proven effective in addressing malnutrition (see annex 4). Not all are feasible in the challenging context of Somalia, requiring a less volatile environment, better access, a stronger public health system, legislative framework and longer term funding. The strategy prioritises what is proven effective with what is feasible and can be adapted to the Somali context. It is also important to note that many of the interventions identified in this strategy correspond to those acknowledged by the Copenhagen Consensus 2008 as the most cost effective interventions for global development (see Annex 5)

- Recognition of the principle of ‘Do no harm’. Respecting this, implementation of strategy should not exacerbate or worsen the situation.

The goal, outcomes, outputs and activities of the strategy have been identified using a logical framework approach. They are based on the priorities, strengths, weaknesses, opportunities and threats identified in the situational analysis and reflect proven effective interventions that are feasible in the challenging context of Somalia. Justification of each outcome and the key approaches adopted are described in annex 6.

The overall development goal of this strategy is to contribute to improved survival and development of Somali people through enhanced nutritional statusThis contribution will be achieved through the accomplishment of the following outcomes (expected benefits to the population) which in turn will be realised by the achievement of the specified outputs through conducting the defined activities.

GOAL, OUTCOMES & OUTPUTS 3

Outputs: 1.1 Quality services for the management of acute

malnutrition are enhanced and expanded

1.2 Quality services for the treatment of micronutrient deficiencies are enhanced and expanded

1.3 Food based interventions for the prevention of undernutrition in identified high risk populations are enhanced and expanded

1.4 Utilisation of available services for the prevention and treatment of acute and chronic malnutrition is increased

Outputs:2.1 Quality nutritional surveillance, monitoring

and evaluation is conducted and reviewed on a timely basis to inform the targeting of vulnerable populations with appropriate responses

2.2 Operational research to identify effective programmes to address the causes of undernutrition is conducted, according to an agreed upon set of priorities and plan of action, and is used as evidence base for long term strategic planning.

Child receives ‘Plumpynut’ from father, Concern Worldwide

Measuring height during a nutrition survey, FSNAU

Outcome 2: Sustained availability of timely and quality nutrition information and operational research into effective responses to address the causes of undernutrition

Outcome 1: Improved access to and utilisation of quality services for the management of malnutrition in malnourished women and children

11

Outputs: 3.1 Improved rates of early initiation and exclusive

breastfeeding practices

3.2 Improved rates of optimal complementary feeding practices

3.3 Local availability and consumption patterns of nutrient dense foods are better understood and this knowledge-base is used to promote increased intake of energy, protein and micronutrient-rich foods

3.4 Common practices that inhibit micronutrient absorption e.g. tea consumption are better understood and addressed

3.5 Improved access to nutrition education and counselling for pregnant and lactating women through health services and community based structures

Outputs:4.1 Increased availability of fortified food

4.2 Improved access to and utilisation of micronutrient supplements and fortified supplementary food by vulnerable groups through health services and novel community based delivery strategies

4.3 Increased coverage of de-worming through population-based delivery mechanisms: a) Child Health Days, b) schools, c) MCH services and d) nutrition programmes

Outputs:5.1 Nutrition is effectively incorporated into

the policies, strategies, activities, delivery mechanisms and outcomes of health sector

5.2 Nutrition is integrated into the policies, strategies, activities, delivery mechanisms and outcomes of relevant sectors (WASH, agriculture/livelihoods, education, food aid)

Mother breastfeeding child at Baidoa MCH, UNICEF Somalia, CK Minihane

Child receives Vitamin A supplementation at CHD in Hargeisa, UNICEF Somalia, Denise Shepherd

Johnson

Promotion of handwashing, DHK Mogadishu, SAACID/WFP

Outcome 3: Increased appropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition

Outcome 4: Improved availability and coverage of micronutrients and de-worming interventions to the population

Outcome 5: Improved mainstreaming of nutrition as a key component of health and other relevant sectors

12

Outputs:6.1 A two year nutrition sector capacity

development strategy and plan of action is developed by the end of 2011

6.2 Capacity development strategy and training activities are implemented according to plan of action

6.3 Regional training and mentoring cells are

formed by the end of 2011.

6.4 Internationally recognised training guidelines and protocols are adapted to the Somali context

6.5 An enabling environment for all stakeholders to implement quality nutrition programmes is created and sustained, in collaboration with local authorities

Nutrition training, Save the Children in Somalia/Somaliland

Outcome 6: Improved capacity and means in country to deliver essential nutrition services

13

The logical framework defining goal, outcomes, outputs and activities and associated indicators for monitoring progress is included in annex 1. In addition, a results-based matrix detailing the activities, responsible agencies and time frame for action will be developed. Due to constraints to rapid scale up of interventions (restrictions in access, logistic, human and financial resources) a phased approach to implementation is proposed. Activities for the first year (phase 1) will be focused on the adaption and standardisation of tools, training and strengthening of structures and mechanisms in preparation for delivery of interventions in Phase 2. In this way, achievements of the first year will build the foundation for subsequent years. In view of the different context and challenges of the three zones, implementation of proposed activities will also be phased by geographical location, depending on access, capacity and resources available.

4.1 Opportunities Restricted access, poor infrastructure and limited means in the face of huge needs means innovative ways of intervening in Somalia are called for. Opportunities arise from existing structures, pilots and programmes which provide entry points for strengthening, scaling up and delivering complementary essential activities. These opportunity areas are summarised below with more detail found in Table 2 of the situational analysis.

• The strength and funding of existing nutrition programmes which provide existing structures through which to deliver essential complementary services (deworming, immunisation, promotion of good hygiene) thereby maximising the potential benefit of nutritional input

• Existing and upcoming interventions and programmes through which quality nutrition activities can be delivered • Accelerated Young Child Survival (AYCS) initiative Child Health Days, GAVI Health System Strengthening (HSS) funded Female Community-based Health Workers & Behaviour Change Communication (BCC) strategy

• Pilot of new interventions with possibilities for scale up – FAO Trials of Improved Practices, Plumpy doz for prevention of moderate malnutrition

• Globally accepted guidelines and proven effective interventions that can be adapted to the Somali context

• WHO community based initiatives (CBI) like Basic Development Needs (BDN) and Healthy City Initiatives – community structures already in place as the basis for community based interventions.

• Mosques and schools provide existing community structures for innovative delivery of population based interventions such as deworming, micronutrient supplementation and nutrition education.

IMPLEMENTATION4

OTP nurse explaining healthy messages to OTP attendants, Baadbuke OTP site Save the Children

14 4.2 PartnershipsImplementation of the strategy will be through partnership-based action, with the national and local authorities (Ministry of Health and other line ministries), with the local community, local NGOs and civil society, with the international community and with the private sector.

a) National and local governmentThroughout the three zones, but more so in Somaliland and Puntland, government structures are in place and evolving. Governments have the responsibility to provide policy direction and leadership, promote inter-ministerial collaboration and advocate with religious and cultural institutions in priority areas. However, capacity is currently inadequate. In response to this, a key output of this strategy is to support the improvement of local capacity and structures within the ministries, in particular technical and financial support for the nutrition sector. Furthermore, this strategy should be included in the respective governments’ plans and priorities for next 3 years.

b) The Community In areas where continuing insecurity and lack of access for international staff persists, implementation through local authorities, local NGOs and community based workers will be key delivery mechanisms. In line with Essential Package of Health Services, UNICEF/WHO’s Accelerated Young Child Survival initiative, the Reproductive Health strategy and GAVI HSS funds, the development of the role of the community health worker is essential for community mobilisation, individual support and promotion of good nutrition, hygiene and health practices.

Furthermore the system of female community-based health workers proposed through GAVI HSS fund will allow expansion of community activities: the promotion of vitamin A for children and post-partum women, prevention and control of diarrhoea, promotion of early initiation and exclusive breastfeeding and appropriate complementary feeding practices for infants and young children, promotion of good nutrition for all the family in particular women, assessment of nutritional status and referral of malnourished children.

Schools, religious and cultural institutions provide important structures within the community through which to deliver population based interventions such as deworming, early identification and referral of acute malnutrition and nutrition education.

c) Local Non Governmental Organisations (NGOs) are very important partners in the delivery of interventions where access to the international community is restricted and government structures are weak. Again, capacity is often a limiting factor and is one of the priority areas to be addressed, in line with national and regional as well as UN national capacity development strategies. The development of regional training and mentoring cells will be an important initiative in improving capacity and the quality of nutrition programmes implemented by these local partners.

d) International community Donors Over recent years, work by FSNAU has achieved a tremendous amount in highlighting the devastating nutrition situation in country and as a consequence, donor funding of emergency programmes has been good. The challenge is to keep nutrition as a priority for donors, UN, NGOs and the ministries and advocate for a longer term strategy in Somalia to address not only the critical acute malnutrition situation but also the underlying causes, if reduced mortality and optimal growth and development are to be addressed.

United Nations (UN) This strategy will build on the already strong collaboration between United Nations (UN) agencies such as UNICEF, FAO/FSNAU, WFP, UNFPA and WHO working to improve maternal and child nutrition and health in Somalia. One key area of collaboration is around strengthening mechanisms to ensure a minimum package of essential services is delivered

15 alongside nutrition programmes in a timely manner.

Under UN humanitarian reform, the cluster approach has been developed to strengthen coordination and give predictability and accountability to the humanitarian response. There are currently nine cluster sectors for Somalia: health, WASH, food aid, agriculture and livelihoods, education, nutrition, protection, logistics and shelter and currently inter cluster working group coordination meetings are held. This strategy places great importance on improving inter cluster and inter working group collaboration for a multi-sector approach to addressing the cross cutting factors that determine nutritional status, growth and development in Somalia.

International Non-Governmental Organizations (NGOs) Although access may be restricted, International NGOs continue to be important partners providing additional technical capacity and skills in nutrition and new innovations in programme delivery.

Academic, Research and Global Advocacy Institutions: A new area to be explored is to access expertise from internationally recognized organizations and improve linkages with local organisations and institutions. Some of these institutions may include: Tufts University, World Alliance for Breastfeeding Action (WABA), International Baby Food Action Network (IBFAN), Micronutrient Initiatives (MI). Links to academic institutions can open up options for the organisation of specific nutrition trainings in the region and distance learning courses.

c) The Private SectorThe private sector in Somalia has an important potential contribution to make towards improving the nutrition situation in country. One of the key areas to engage with the private sector on is the control of the marketing and promotion of breast milk substitutes, possibly looking at supporting the private sector to promote appropriate complementary foods to prevent malnutrition in place of infant formula. Advocacy and sensitisation of the private sector on the International Code on marketing of breast milk substitutes is an important first step towards a longer term consultative process on its adoption. The private sector also has a key role to be explored in the potential for importing fortified foods, in particular cereal flours. In addition, there are opportunities for developing private public partnerships in the social marketing of micronutrient supplements as has been successfully applied to low cost water purification tablets and long lasting insecticide treated bed nets in Somaliland.

4.3 Zonal differencesThe overall goal and outcomes are the same for Somaliland, Puntland and South Central Somalia but the situational analysis provides evidence of the need for a different approach to implementation in the different zones. Coverage of services for the management of acute malnutrition has improved considerably in the last few years. Maintaining these achievements and striving for improved quality of services is particularly important in South Central Somalia where rates of acute malnutrition were found to be the highest of all zones in the recent Post deyr 09/10 seasonal assessment (median GAM 19%, median SAM 4.4%) and 81% of acutely malnourished live. Yet here is where structure and systems through which to implement are more limited and humanitarian space to intervene is most restricted. To overcome these challenges, there is a need to concentrate on implementing through local NGOs and community-based initiatives as government structures emerge and evolve. Until the situation becomes more secure, programmes must be managed by remote control and innovative mechanisms for delivery of interventions developed. Many of the important public health initiatives proposed in the action plan may need to be started on a smaller local basis, to be scaled up as the political and security situation allows.

16 In Somaliland and to a lesser extent Puntland, more or less stable government institutions have been formed providing greater opportunities for partnerships. However as yet, capacity, coordination and policy or regulatory framework is limited. The relative peace and stability allows greater access for intervention, monitoring and supervision. In the north, support needs to focus on the increasing numbers of IDPs who, despite some improvement in acute malnutrition rates between Post Gu 09 and Post Deyr 09/10 seasonal assessments (median GAM down from 20% to 16.7%, median SAM down from 4.8% to 4.2%) remain one of the most nutritionally vulnerable group of all livelihoods, with the highest median stunting rate of 25%.

4.4 Operational researchAlthough extensive information is gathered through FSNAU, FEWSNET, WFP food security and vulnerability assessments, gaps remain in knowledge of many areas including:• local availability of nutrient dense foods, of food habits, taboos and other factors that influence

consumption of nutrient dense foods, •enabling factors and barriers to optimal breast feeding, young child and maternal feeding practices, •economic and cultural dynamics of breast milk substitutes, •opportunities for engagement with private sector in areas of breast milk substitutes and food

fortification, • innovative population based delivery mechanisms for micronutrient supplementation, deworming,

nutrition education and behaviour change communication.

In each of these areas, operational research has been identified as a key activity by which to inform and guide appropriate intervention and links with achieving output 2.2.

4.5 Technical supportThere will be a need to commission consultants with particular expertise in certain areas including economics, food fortification, infant and young child feeding, to provide clearer understanding of current situation, identify potential for future interventions and formulate action plans.

4.6 Behaviour Change CommunicationMany of the output results require attitude and behaviour change on an individual and community basis (early initiation of and exclusive breastfeeding for 6 months, optimal complementary feeding practices, food safety, increased dietary diversity, hygiene practices, demand for micronutrient supplementation and reduction of practices inhibiting micronutrient absorption, appropriate health and nutrition seeking behaviours). There is often overlap with priorities of other sectors eg promotion of food safety goes hand in hand with good hygiene practices. In response, a comprehensive and integrated behaviour change communication strategy approach is needed with the development of key simple messages and the identification of delivery channels that are appropriate and effective in the Somali context. Messages should be communicated through more than one channel for maximum effect: on an individual basis through interpersonal counselling by community health workers and breast feeding counsellors, and mobilising communities through mosques, schools and local institutions and mass media campaigns.

Breastfeeding Counselling, IDPs, Hargeisa, UNICEF Somalia, Iman Morooka

MONITORING5This strategy covers a 3 year period. The overall goal is to contribute to improved survival and development of Somali people through enhanced nutritional status. Trends in under-five and infant mortality rates and nutritional status indicators will be monitored through MICS and FSNAU nutrition surveillance data. However, because three years is too short a period in which to see significant changes these will not be used as the main indicators of the extent to which objectives have been achieved.

The results matrix gives details of the output and outcome (impact) and activity (process) indicators and their source of verification against which effectiveness of the strategy will be measured. The main sources of verification include: FSNAU surveillance data which provides valuable, quality information on a range of indicators; MICS, which was last conducted in 2006 although there were technical issues with the quality of nutrition data in particular, and is planned for 2011 and repeated after 3 years; implementing partner reports and the Health Information System, which has been of low quality and irregular but for which there are ongoing efforts to improve quality through simplification of reporting forms, training, analysis and regular feedback. FSNAU KAPS 2007 and the National Micronutrient and Anthropometric Nutrition Survey 2009 have provided valuable baseline information on a number of key indicators. To facilitate the coordination and monitoring activities of the strategy implementation, responsibility of specific agencies for each activity will be defined.

The strategy will be reviewed and updated on a regular basis not least because the security and access situations can change substantially in Somalia thereby affecting feasibility of implementation. The inter-agency review process of progress on implementation will be led by the Ministries of Health in collaboration with technical support of the Health Sector Committee and undertaken with the involvement of all stakeholders. Line ministries will have a key input into the review process, while the agency focus will depend on the specific activities under review. The annual review will be timed to occur prior to the CAP so findings can inform and identity funding priorities for CAP. Reports on progress will be disseminated to donors, national and implementation partners on an annual basis. A full review of progress made in the implementation of the strategy will be undertaken after the first year (phase 1) and again after the subsequent two years.

ANNEXES

ANNEX 1

18

19 P

roje

ct

de

sc

rip

tio

n

Ind

ica

tors

S

ou

rce

of

ve

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tio

n

As

su

mp

tio

ns

Go

al:

To

co

ntr

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pro

ve

d s

urv

iva

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ve

lop

me

nt

of

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ple

th

rou

gh

en

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d n

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na

l sta

tus

Ou

tco

me

1:

Imp

rove

d a

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o a

nd

utilis

atio

n o

f q

ua

lity s

erv

ice

s

for

the

ma

na

ge

me

nt

of

ma

lnu

tritio

n in

wo

me

n a

nd

ch

ildre

n

1a

75

% a

cu

tely

ma

lno

uri

sh

ed

ch

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n

an

d p

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na

nt

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d la

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g w

om

en

ha

ve

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utilis

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s f

or

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na

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of

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1b

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of

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ith

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to

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me

pe

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in

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rs

da

tab

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FS

NA

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ta

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(lim

ite

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HM

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Mo

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facili

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ase

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Au

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tatio

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Ou

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ts:

1.1

Q

ua

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s f

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the

ma

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of

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nd

exp

an

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1.2

Q

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s f

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1.1

a

70

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f ta

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xp

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Imp

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UN

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Fa

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CH

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LOGICAL FRAMEWORKANNEX 1

1.3

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s:

1.1

.1

Ba

se

d o

n b

i a

nn

ua

l re

vie

w o

f n

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n s

itu

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t ta

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1.1

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Pro

vid

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up

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ch

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al su

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ort

on

a

tim

ely

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sis

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De

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an

d im

ple

me

nt

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uid

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sp

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to

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ma

li co

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l

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en

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n t

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ad

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om

mu

nitie

s

1.1

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Co

nd

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co

mm

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n w

ith

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d r

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ase

co

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1.1

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n p

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me

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ind

ica

tors

are

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thly

1.1

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i) N

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sse

sse

d a

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ta

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et

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ry s

ix m

on

ths,

ii) N

ew

se

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in

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l

1.1

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nu

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tock o

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S

PH

ER

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or

pro

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mm

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by

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% p

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1.1

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gu

ide

line

s a

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d

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ly a

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d b

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of

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1.1

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a)

nu

mb

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mm

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n c

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) p

rop

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ion

of

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mp

lica

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to

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co

mp

lica

ted

SA

M c

ase

s2

1.1

.5

80

% im

ple

me

ntin

g a

ge

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s

rep

ort

ing

mo

nth

ly

Me

etin

g r

ep

ort

s o

f re

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w

an

d t

arg

ets

se

t

Imp

lem

en

tin

g a

ge

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s

rep

ort

s

HM

IS,

UN

ICE

F &

WF

P

su

pp

ly d

ata

UN

ICE

F d

ata

ba

se

Pu

blis

he

d g

uid

elin

es,

imp

lem

en

tin

g p

art

ne

rs

rep

ort

s

Imp

lem

en

tin

g p

art

ne

rs

rep

ort

s

UN

ICE

F d

ata

ba

se

Se

cu

rity

situ

atio

n a

llow

s

acce

ss f

or

su

rve

illa

nce

,

imp

lem

en

tatio

n a

nd

utilis

atio

n o

f se

rvic

es

Ad

eq

ua

te h

um

an

, fin

an

cia

l

an

d m

ate

ria

l re

so

urc

es

ava

ilab

le

Eff

icie

nt

log

istics s

yste

m f

or

tim

ely

de

live

ry o

f a

de

qu

ate

su

pp

lies

Ne

w g

uid

elin

es a

cce

pte

d a

nd

ad

op

ted

by p

art

ne

rs

Ta

rge

t p

op

ula

tio

n o

pe

n t

o

me

ssa

ge

s

Re

po

rts a

re r

elia

ble

20

1.1

.6

Ad

vo

ca

te t

o e

nsu

re d

elive

ry o

f b

asic

esse

ntia

l

he

alth

se

rvic

es (

imm

un

isa

tio

n,

de

-wo

rmin

g e

tc)

thro

ug

h n

utr

itio

n p

rog

ram

me

s

1.2

.1

Re

vie

w m

icro

nu

trie

nt

su

rve

y r

esu

lts a

nd

HM

IS

da

ta w

he

re a

va

ila

ble

an

d s

et

targ

ets

fo

r

en

ha

nce

me

nt

of

MN

D t

rea

tme

nt

se

rvic

es

1.2

.2

De

ve

lop

& im

ple

me

nt

sim

ple

So

ma

li s

pe

cific

sta

nd

ard

ise

d p

roto

co

ls f

or

the

tre

atm

en

t o

f

mic

ron

utr

ien

t d

eficie

ncie

s,

with

re

gio

na

l ro

ll o

ut

1.2

.3

De

ve

lop

an

d im

ple

me

nt

sim

ple

sta

nd

ard

ise

d

pro

toco

l fo

r th

era

pe

utic z

inc s

up

ple

me

nta

tio

n in

the

ma

na

ge

me

nt

of

dia

rrh

oe

a

1.2

.4

Pro

vid

e a

nd

ma

na

ge

su

pp

lie

s a

nd

pro

vid

e

tech

nic

al su

pp

ort

on

a t

ime

ly b

asis

1.2

.5

Pla

n a

nd

im

ple

me

nt

in-s

erv

ice

tra

inin

g o

f

he

alth

fa

cility s

taff

at

all le

ve

ls o

n d

iag

no

sis

an

d

tre

atm

en

t p

roto

co

ls

1.2

.6

Co

nd

uct

co

mm

un

ity m

ob

ilis

atio

n c

am

pa

ign

s o

n

MN

D

1.3

.1

Asse

ss n

ee

ds a

nd

id

en

tify

vu

lne

rab

le

po

pu

latio

ns t

hro

ug

h b

i a

nn

ua

l re

vie

w o

f q

ua

lity

nu

tritio

n a

nd

fo

od

se

cu

rity

se

aso

na

l

asse

ssm

en

ts

1.3

.2

Ba

se

d o

n a

bo

ve

, e

sta

blish

ne

w n

utr

itio

n

se

rvic

es f

or

pre

ve

ntio

n o

f u

nd

ern

utr

itio

n,

1.1

.6

Ad

vo

ca

cy is c

arr

ied

ou

t

1.2

.1

Su

rve

y r

esu

lts a

nd

HM

IS d

ata

revie

we

d a

nd

ta

rge

ts s

ets

1.2

.2

a)

Sta

nd

ard

ise

d p

roto

co

ls

de

ve

lop

ed

by e

nd

of

ph

ase

1

b)

incre

asin

g t

ren

ds in

x%

he

alth

facilitie

s im

ple

me

ntin

g t

rea

tme

nt

pro

toco

ls a

cro

ss t

he

re

gio

ns

3

1.2

.3

a

) S

tan

da

rdis

ed

pro

toco

ls

de

ve

lop

ed

by e

nd

of

ph

ase

1

b

) 8

0%

ch

ild

ren

att

en

din

g M

CH

exp

eri

en

cin

g d

iarr

ho

ea

wh

o

rece

ive

th

era

pe

utic z

inc

su

pp

lem

en

tatio

n b

y e

nd

ph

ase

2

1.2

.4

Nu

mb

er

of

da

ys o

f sto

ck o

uts

of

mic

ron

utr

ien

t tr

ea

tme

nts

1.2

.5

a)

Nu

mb

er

of

he

alth

fa

cilitie

s w

ith

sta

ff t

rain

ed

an

d a

ctive

in

tre

atm

en

t o

f m

icro

nu

trie

nt

de

ficie

ncie

s

1.2

.6

Nu

mb

er

of

ca

mp

aig

ns c

on

du

cte

d

1.2

.1

Bi a

nn

ua

l re

vie

w c

on

du

cte

d a

nd

targ

et

po

pu

latio

ns id

en

tifie

d

1.2

.2

Fo

od

-ba

se

d in

terv

en

tio

ns t

o

pre

ve

nt

un

de

rnu

tritio

n a

re

Do

cu

me

nta

tio

n

Do

cu

me

nta

tio

n

Do

cu

me

nta

tio

n

HM

IS

Fa

cility s

urv

ey

Do

cu

me

nta

tio

n

HM

IS

HM

IS s

up

ply

da

ta

Ne

w d

ata

ba

se

on

he

alth

pe

rso

nn

el &

tra

inin

g

rece

ive

d

Activity r

ep

ort

s

Re

po

rts o

f re

vie

w a

nd

targ

ets

id

en

tifie

d

Imp

lem

en

tin

g a

ge

ncie

s

rep

ort

s

He

alth

se

cto

r re

ce

ptive

,

ad

eq

ua

te s

up

plie

s a

nd

log

istic s

yste

m a

va

ila

ble

Re

su

lts a

re r

elia

ble

Su

ffic

ien

t su

pp

lie

s a

nd

eff

icie

nt

log

istica

l su

pp

ort

ava

ila

ble

He

alth

fa

cility s

taff

mo

tiva

ted

Co

mm

un

ity r

ece

ptive

Da

ta a

nd

re

vie

w a

re r

elia

ble

Su

pp

lem

en

tary

fo

od

s a

re

acce

pta

ble

to

an

d u

se

d

21

22

(in

clu

din

g lip

id-b

ase

d n

utr

ien

t su

pp

lem

en

ts-

LN

S)

in id

en

tifie

d h

igh

ris

k p

op

ula

tio

ns

1.3

.3

Co

nd

uct

tra

inin

g o

f h

ea

lth

wo

rke

rs a

nd

imp

lem

en

tin

g p

art

ne

rs o

n n

ew

se

rvic

es,

inclu

din

g c

ou

nse

llin

g o

n c

on

tin

ue

d

bre

astf

ee

din

g a

nd

fo

od

hyg

ien

e p

ractice

s

1.3

.4

Pro

vid

e a

nd

ma

na

ge

su

pp

lies a

nd

pro

vid

e

tech

nic

al su

pp

ort

to

im

ple

me

ntin

g p

art

ne

rs o

n

a t

ime

ly b

asis

1.3

.5

Co

nd

uct

co

mm

un

ity s

en

sitis

atio

n t

o m

axim

ise

acce

pta

bili

ty a

nd

ap

pro

pri

ate

use

of

foo

d b

ase

d

inte

rve

ntio

ns

1.3

.6

Asse

ss a

nd

re

vie

w c

on

tin

ua

tio

n o

f fo

od

ba

se

d

inte

rve

ntio

ns,

ba

se

d o

n n

utr

itio

n s

urv

eill

an

ce

da

ta a

nd

bi a

nn

ua

l se

aso

na

l a

sse

ssm

en

ts

1.4

.1

C

on

du

ct

co

mm

un

ity a

wa

ren

ess a

nd

mo

bili

sa

tio

n c

am

pa

ign

s t

o in

cre

ase

aw

are

ne

ss

an

d u

nd

ers

tan

din

g o

f a

va

ilab

le s

erv

ice

s

esta

blis

he

d in

id

en

tifie

d h

igh

ris

k

are

as

1.2

.3

Nu

mb

er

of

he

alth

wo

rke

rs a

nd

imp

lem

en

tin

g s

taff

tra

ine

d

1.2

.4

Nu

mb

er

of

da

ys o

f sto

ck o

uts

1.2

.5

Nu

mb

er

of

co

mm

un

ity

se

nsitis

atio

n c

am

pa

ign

s

co

nd

ucte

d

1.2

.6

Bi a

nn

ua

l re

vie

ws c

on

du

cte

d

1.4

.1

nu

mb

er

of

co

mm

un

ity c

am

pa

ign

s

co

nd

ucte

d

Tra

inin

g r

ep

ort

s,

he

alth

wo

rke

r tr

ain

ing

da

tab

ase

,

pa

rtn

er

rep

ort

s

Su

pp

ly d

ata

Activity r

ep

ort

s

Re

vie

w r

ep

ort

s

Activity r

ep

ort

s

ap

pro

pri

ate

ly b

y t

arg

et

gro

up

s

He

alth

wo

rke

rs a

nd

pro

gra

mm

e s

taff

are

mo

tiva

ted

Su

ffic

ien

t su

pp

lies a

nd

eff

icie

nt

log

istics s

yste

m in

pla

ce

Co

mm

un

ity is r

ece

ptive

Su

rve

illa

nce

da

ta is r

elia

ble

Co

mm

un

ity is r

ece

ptive

23

Ou

tco

me

2

Pro

jec

t d

es

cri

pti

on

Ind

ica

tors

S

ou

rce

of

ve

rifi

ca

tio

n

As

su

mp

tio

ns

Ou

tco

me

2:

Su

sta

ine

d a

va

ila

bility o

f tim

ely

an

d q

ua

lity

nu

tritio

n

info

rma

tio

n a

nd

op

era

tio

na

l re

se

arc

h in

to e

ffe

ctive

resp

on

se

s t

o a

dd

ress t

he

ca

use

s o

f u

nd

ern

utr

itio

n

Nu

mb

er

of

info

rma

tio

n u

se

rs

(go

ve

rnm

en

t, in

stitu

tio

ns,

civ

il s

ocie

ty,

Dia

sp

ora

, IN

GO

s,

UN

ag

en

cie

s,

do

no

rs,

oth

ers

) re

ce

ivin

g n

utr

itio

n in

form

atio

n t

o

incre

ase

by 4

0%

aft

er

3 y

ea

rs

Nu

mb

er

of

info

rma

tio

n u

se

rs b

ase

d in

So

ma

lia

re

ce

ivin

g n

utr

itio

n in

form

atio

n t

o

incre

ase

by 4

0%

aft

er

3 y

ea

rs

Evid

en

ce

of

FS

NA

U a

na

lysis

be

ing

pri

ma

ry in

form

an

t to

hu

ma

nita

ria

n a

pp

ea

l

an

d r

esp

on

se

pro

ce

ss a

nd

evid

en

ce

of

ch

an

ge

s in

th

e r

esp

on

se

an

d

pro

ce

ss(C

AP

/HR

F/C

ER

F)

Evid

en

ce

of

nu

tritio

n a

na

lysis

in

form

ing

the

Re

co

nstr

uctio

n &

De

ve

lop

me

nt

Pla

n

(RD

P),

Un

ite

d N

atio

ns T

ran

sitio

n P

lan

(UN

TP

), A

gri

cu

ltu

re S

ecto

r S

tra

teg

ic

Fra

me

wo

rk (

AS

SF

), a

nd

Co

un

try S

tra

teg

y

Pa

pe

r (C

SP

) a

nd

evid

en

ce

of

ch

an

ge

s in

the

de

sig

n a

nd

mo

nito

rin

g o

f th

ese

initia

tive

s

Evid

en

ce

of

nu

tritio

n a

na

lysis

in

form

ing

the

So

ma

lia

Su

pp

ort

Se

cre

tari

at

(SS

S)

So

ma

lia

nu

tritio

n

info

rma

tio

n a

ge

ncy

we

bsite

hits (

FS

NA

U,

UN

ICE

F,

WH

O,

OC

HA

), m

ailin

g lis

ts,

me

etin

g p

art

icip

atio

n,

nu

tritio

n u

nit o

f M

oH

s

CA

P,

CE

RF

, H

RF

rep

ort

s

RD

P d

ocu

me

nt

Clu

ste

r m

ee

tin

g

Pa

rtn

ers

an

d d

on

ors

rece

ptive

to

nu

tritio

n

info

rma

tio

n

Nu

tritio

n in

form

atio

n is

inte

rpre

ted

ap

pro

pri

ate

ly t

o

info

rm d

ecis

ion

s r

eg

ard

ing

fea

sib

le r

esp

on

se

s

Se

cu

rity

situ

atio

n a

llo

ws

acce

ss t

o r

esp

on

d t

o

nu

tritio

n in

form

atio

n

ava

ila

ble

Au

tho

ritie

s,

lin

e m

inis

trie

s,

arm

ed

gro

up

s a

re

su

pp

ort

ive

an

d p

rovid

e

ne

ce

ssa

ry c

on

ditio

ns t

o

resp

on

d

24 se

cto

r w

ork

ing

gro

up

s a

nd

th

e I

AS

C

Clu

ste

r a

ctio

n p

lan

s a

nd

evid

en

ce

of

de

cis

ion

s in

flu

en

ce

d b

y t

his

an

aly

sis

Nu

tritio

n

an

aly

sis

an

d in

form

atio

n

co

ntr

ibu

tin

g t

o 5

0%

of

the

se

cto

r stu

die

s

an

d s

tra

teg

ic p

lan

nin

g u

nd

ert

ake

n b

y

So

ma

li g

ove

rnm

en

t, d

on

ors

, U

N

ag

en

cie

s,

ING

Os

min

ute

s

Str

ate

gic

pla

nn

ing

rep

ort

s

Ou

tpu

ts:

2.1

Q

ua

lity

nu

tritio

na

l su

rve

illa

nce

, m

on

ito

rin

g a

nd

eva

lua

tio

n is c

on

du

cte

d a

nd

re

vie

we

d o

n a

tim

ely

ba

sis

to

in

form

th

e t

arg

etin

g o

f vu

lne

rab

le

po

pu

latio

ns w

ith

ap

pro

pri

ate

re

sp

on

se

s

2.2

O

pe

ratio

na

l re

se

arc

h t

o id

en

tify

eff

ective

pro

gra

mm

es t

o a

dd

ress t

he

ca

use

s o

f

un

de

rnu

tritio

n is c

on

du

cte

d,

acco

rdin

g t

o a

n a

gre

ed

up

on

se

t o

f p

rio

ritie

s a

nd

pla

n o

f a

ctio

n,

an

d is u

se

d

as e

vid

en

ce

ba

se

fo

r lo

ng

te

rm s

tra

teg

ic p

lan

nin

g

2.1

a 1

00

% s

urv

eys a

re v

alid

ate

d u

sin

g

pla

usib

ility c

he

cks.

2.1

b >

90

% o

f su

rve

ys m

ee

t th

e c

rite

ria

of

qu

ality

fo

r p

ub

lish

ing

re

su

lts

2.1

b R

esu

lts o

f b

ian

nu

al n

utr

itio

n

asse

ssm

en

ts a

re r

ele

ase

d a

nd

re

vie

we

d

in J

an

ua

ry (

po

st

De

yr)

an

d A

ug

ust

(po

st

Gu

) o

f e

ach

ye

ar

2.2

x%

re

se

arc

h p

roje

cts

un

de

rta

ke

n

acco

rdin

g t

o d

efin

ed

pla

n o

f a

ctio

n4

FS

NA

U t

ech

nic

al se

rie

s

rep

ort

s

Do

cu

me

nta

tio

n o

f

FS

NA

U s

ea

so

na

l

asse

ssm

en

t re

lea

se

da

tes

Do

cu

me

nta

tio

n o

f

nu

mb

er

of

rese

arc

h

rep

ort

s p

rod

uce

d

Da

ta c

olle

ctio

n is r

elia

ble

Activitie

s

2.1

.1

Co

nd

uct

reg

ula

r in

ter-

ag

en

cy n

utr

itio

n s

urv

eys

thro

ug

ho

ut

live

lih

oo

d z

on

es a

cco

rdin

g t

o

ag

ree

d u

po

n s

ch

ed

ule

an

d in

ter-

se

cto

ral

info

rma

tio

n r

eq

uir

em

en

ts.

2.1

.1a

>9

0%

pla

nn

ed

nu

tritio

n s

urv

eys

co

nd

ucte

d

2.1

.1b

Pa

rtn

ers

in

vo

lve

d in

10

0%

of

the

su

rve

ys f

or

ow

ne

rsh

ip

2.1

.1c 1

00

% p

re-a

gre

ed

in

ter-

se

cto

ral

FS

NA

U t

ech

nic

al se

rie

s

rep

ort

s,

Bi m

on

thly

Nu

tritio

n U

pd

ate

s

Se

cu

rity

situ

atio

n a

llo

ws

acce

ss

Su

ffic

ien

t fin

an

cia

l, h

um

an

reso

urc

es a

nd

ma

teri

al

25

2.1

.2

An

aly

se

su

rve

y r

esu

lts a

nd

in

terp

ret

in c

on

text

of

oth

er

rele

va

nt

su

rve

illa

nce

da

ta (

MC

H d

ata

,

ava

ilab

ility

of

nu

tritio

n p

rog

ram

me

s,

acce

ss t

o

he

alth

se

rvic

es,

dis

ea

se

ou

tbre

aks,

wa

ter

an

d

sa

nita

tio

n,

foo

d s

ecu

rity

in

form

atio

n)

2.1

.3

Un

de

rta

ke

bia

nn

ua

l m

ap

pin

g o

f n

utr

itio

n

situ

atio

n b

y liv

elih

oo

d z

on

e,

acco

rdin

g t

o I

PC

cla

ssific

atio

n

2.1

.4

Pro

du

ce

re

gu

lar

nu

tritio

n u

pd

ate

s a

nd

re

po

rts

inclu

din

g:

Qu

art

erl

y F

oo

d s

ecu

rity

an

d n

utr

itio

n

bri

ef,

Bia

nn

ua

l F

oo

d S

ecu

rity

an

d N

utr

itio

n

bri

ef,

bi a

nn

ua

l te

ch

nic

al se

rie

s r

ep

ort

s.

2.2

.1

Pri

ori

ty a

rea

s f

or

op

era

tio

na

l re

se

arc

h in

to

un

de

rlyin

g c

au

se

s o

f u

nd

ern

utr

itio

n id

en

tifie

d

an

d p

lan

of

actio

n d

evis

ed

to

in

clu

de

activitie

s

3.1

.1,

3.2

.1,

3.3

.1,

3.4

.1,

3.5

.3,

4.2

.6,

4.2

.8

2.2

.2

Co

nd

uct

op

era

tio

na

l re

se

arc

h a

cco

rdin

g t

o p

lan

of

actio

n

2.2

.3

Pro

du

ce

re

se

arc

h r

ep

ort

s,

dis

se

min

ate

an

d u

se

fin

din

gs t

o in

form

ap

pro

pri

ate

nu

tritio

n

resp

on

se

s

info

rma

tio

n r

eq

uir

em

en

ts (

WA

SH

,

He

alth

, M

ala

ria

, F

oo

d S

ecu

rity

)

ad

dre

sse

d

2.1

.2 1

00

% p

ub

lish

ed

su

rve

y r

ep

ort

s

inclu

de

co

nte

xtu

al a

na

lysis

2.1

.3 M

ap

s p

rod

uce

d o

n a

bia

nn

ua

l b

asis

2.1

.4 N

utr

itio

n r

ep

ort

s p

rod

uce

d a

cco

rdin

g

to d

efin

ed

sch

ed

ule

2.2

.1 L

ist

of

pri

ori

tie

s a

rea

s a

nd

pla

n o

f

actio

n id

en

tifie

d

2.2

.2 R

ese

arc

h is c

on

du

cte

d

2.2

.3 R

ese

arc

h r

ep

ort

s p

ub

lish

ed

an

d

dis

se

min

ate

d

Ma

ps p

rod

uce

d

Re

po

rts p

rod

uce

d

Pu

blis

he

d r

ep

ort

s

reso

urc

es a

va

ilab

le

Imp

lem

en

tin

g p

art

ne

rs,

au

tho

ritie

s,

line

min

istr

ies,

arm

ed

gro

up

s a

re

su

pp

ort

ive

an

d p

rovid

e

ne

ce

ssa

ry c

on

ditio

ns t

o

co

nd

uct

su

rve

ys &

re

se

arc

h

26 O

utc

om

e 3

Pro

jec

t d

es

cri

pti

on

Ind

ica

tors

S

ou

rce

of

ve

rifi

ca

tio

n

As

su

mp

tio

ns

Ou

tco

me

3:

Incre

ase

d a

pp

rop

ria

te k

no

wle

dg

e,

att

itu

de

s a

nd

pra

ctice

s r

eg

ard

ing

in

fan

t, y

ou

ng

ch

ild

an

d m

ate

rna

l

nu

tritio

n

50

% in

cre

ase

in

ap

pro

pri

ate

kn

ow

led

ge

,

att

itu

de

s a

nd

pra

ctice

s r

eg

ard

ing

in

fan

t,

yo

un

g c

hild

an

d m

ate

rna

l n

utr

itio

n

KA

P s

tud

y

MIC

S

Acce

ss t

o f

un

ctio

nin

g h

ea

lth

se

rvic

es

Acce

ss t

o f

oo

d s

ecu

rity

Acce

ss t

o h

ea

lth

y

en

vir

on

me

nt

Ou

tpu

ts:

3.1

Im

pro

ve

d r

ate

s o

f e

arl

y in

itia

tio

n a

nd

exclu

siv

e

bre

astf

ee

din

g p

ractice

s

3.2

Im

pro

ve

d r

ate

s o

f o

ptim

al co

mp

lem

en

tary

fe

ed

ing

pra

ctice

s

3.3

Lo

ca

l a

va

ila

bility a

nd

co

nsu

mp

tio

n p

att

ern

s o

f

nu

trie

nt

de

nse

fo

od

s a

re b

ett

er

un

de

rsto

od

an

d

kn

ow

led

ge

-ba

se

is u

se

d t

o p

rom

ote

in

cre

ase

d

inta

ke

of

en

erg

y,

pro

tein

an

d m

icro

nu

trie

nt-

rich

foo

ds

3.4

Co

mm

on

p

ractice

s

tha

t in

hib

it

mic

ron

utr

ien

t

ab

so

rptio

n a

re b

ett

er

un

de

rsto

od

an

d a

dd

resse

d

3.5

Im

pro

ve

d a

cce

ss t

o n

utr

itio

n c

ou

nse

llin

g f

or

pre

gn

an

t a

nd

la

cta

tin

g w

om

en

th

rou

gh

he

alth

se

rvic

es a

nd

co

mm

un

ity b

ase

d s

tru

ctu

res

3.1

R

ate

s o

f e

arl

y in

itia

tio

n a

nd

exclu

siv

e b

rea

stf

ee

din

g d

ou

ble

fro

m

ba

se

lin

e (

5%

)5

3.2

R

ate

s o

f o

ptim

al co

mp

lem

en

tary

fee

din

g p

ractice

s –

ag

e a

t

intr

od

uctio

n,

die

tary

div

ers

ity,

me

al

fre

qu

en

cy –

do

ub

le f

rom

ba

se

lin

e

(11

%)6

3.3

a

) L

oca

l a

va

ila

bility a

nd

co

nsu

mp

tio

n

pa

tte

rns o

f n

utr

ien

t d

en

se

fo

od

s a

re

ide

ntifie

d,

do

cu

me

nte

d a

nd

use

d in

BC

C

3.4

R

ed

uctio

n in

co

mm

on

pra

ctice

s t

ha

t

inh

ibit m

icro

nu

trie

nt

ab

so

rptio

n

(ba

se

lin

e f

req

ue

nt

tea

co

nsu

mp

tio

n

72

%)7

3.5

a

80

% p

reg

na

nt

an

d la

cta

tin

g w

om

en

att

en

din

g M

CH

se

rvic

es a

cce

ss

nu

tritio

n c

ou

nse

llin

g

MIC

S,

Mic

ron

utr

ien

t

su

rve

y

MIC

S,

FS

NA

U

ho

use

ho

ld n

utr

itio

n

asse

ssm

en

t d

ata

,

CS

I –

co

pin

g s

tra

teg

ies

ind

ex

Re

po

rt

HM

IS

Se

cu

rity

situ

atio

n a

llo

ws

acce

ss f

or

imp

lem

en

tatio

n

an

d u

tilisa

tio

n o

f se

rvic

es

27

3.5

b N

um

be

r o

f p

reg

na

nt

an

d la

cta

tin

g

wo

me

n r

ece

ivin

g n

utr

itio

n

co

un

se

llin

g t

hro

ug

h c

om

mu

nity

ba

se

d d

elive

ry m

ech

an

ism

Activity r

ep

ort

s

Ta

rge

t g

rou

ps c

om

ply

with

ad

vic

e

Activitie

s:

3.1

.1

Co

nd

uct

form

ative

re

se

arc

h t

o u

nd

ers

tan

d

cu

rre

nt

pra

ctice

s &

asse

ss b

arr

iers

an

d

op

po

rtu

nitie

s t

o o

ptim

al b

rea

st

fee

din

g

pra

ctice

s

3.1

.2

De

ve

lop

an

d im

ple

me

nt

an

IY

CF

tra

inin

g p

lan

an

d c

urr

icu

la f

or

co

mm

un

ity b

ase

d

bre

astf

ee

din

g c

ou

nse

llo

rs (

BF

C)

an

d M

CH

sta

ff,

inclu

din

g t

rain

ing

of

ma

ste

r tr

ain

ers

3.1

.3

Pro

vid

e in

div

idu

al co

un

se

llin

g a

nd

su

pp

ort

fo

r

exclu

siv

e b

rea

st

fee

din

g t

hro

ug

h a

ne

two

rk o

f

tra

ine

d c

om

mu

nity b

ase

d B

FC

& M

CH

sta

ff

3.1

.4

Re

vie

w a

nd

ad

ap

t IA

SC

/ E

NN

/IF

E ‘In

teg

ratio

n

of

IYC

F s

up

po

rt in

to C

MA

M’ m

ate

ria

ls t

o t

he

So

ma

li c

on

text

3.1

.5

Pilo

t In

teg

ratio

n o

f IY

CF

su

pp

ort

in

to C

MA

M

ap

pro

ach

in

sp

ecifie

d O

TP

s

3.1

.6

De

ve

lop

an

d d

isse

min

ate

ke

y m

essa

ge

s &

ma

teri

als

fo

r m

ob

ilis

ing

co

mm

un

ity s

up

po

rt f

or

op

tim

al b

rea

stf

ee

din

g t

hro

ug

h a

pp

rop

ria

te

de

live

ry s

tra

teg

ies,

inclu

din

g g

ran

dm

oth

ers

,

relig

iou

s/c

om

mu

nity g

rou

ps a

nd

le

ad

ers

an

d

ma

ss m

ed

ia c

ha

nn

els

3.1

.7

Co

nd

uct

ma

rke

t ch

ain

an

aly

sis

of

bre

ast

milk

su

bstitu

tes

3.1

.8

En

ga

ge

with

pri

va

te s

ecto

r a

nd

de

ve

lop

&

imp

lem

en

t a

n a

dvo

ca

cy s

tra

teg

y f

or

3.1

.1 B

arr

iers

& o

pp

ort

un

itie

s id

en

tifie

d

3.1

.2a

ma

ste

r tr

ain

ers

are

tra

ine

d

3.1

.2b

cu

rric

ulu

m is d

eve

lop

ed

3.1

.2c t

rain

ing

pla

n is im

ple

me

nte

d

3.1

.3a

nu

mb

er

of

BF

C t

rain

ed

an

d a

ctive

3.1

.3b

nu

mb

er

MC

H c

en

tre

s p

rovid

ing

bre

astf

ee

din

g c

ou

nse

llin

g

3.1

.4 M

ate

ria

ls a

da

pte

d b

y e

nd

of

ph

ase

1

3.1

.5 P

ilo

ts c

on

du

cte

d in

sp

ecifie

d O

TP

s

3.1

.6a

IE

C m

ate

ria

ls d

eve

lop

ed

3.1

.6b

Me

ssa

ge

s d

isse

min

ate

d t

hro

ug

h

ide

ntifie

d d

elive

ry s

tra

teg

ies

3.1

.7 R

ep

ort

is c

om

ple

ted

an

d

dis

se

min

ate

d

3.1

.8 A

dvo

ca

cy s

tra

teg

y is d

eve

lop

ed

Re

se

arc

h r

ep

ort

Activity r

ep

ort

s

Cu

rric

ulu

m d

ocu

me

nt

pu

blish

ed

Re

po

rts

Fa

cility s

urv

ey (

GA

VI

HS

S)

Do

cu

me

nta

tio

n

Imp

lem

en

tin

g p

art

ne

r

rep

ort

s

Pu

blish

ed

ma

teri

als

Do

cu

me

nta

tio

n

Pu

blish

ed

re

po

rt

Pu

blish

ed

str

ate

gy

Fin

din

gs a

re r

elia

ble

Co

un

se

llo

rs a

re m

otiva

ted

to p

rovid

e s

up

po

rt

He

alth

fa

cility s

taff

are

mo

tiva

ted

to

pro

vid

e

co

un

se

llin

g

Re

so

urc

es a

va

ila

ble

Se

cu

rity

situ

atio

n a

llo

ws

Co

mm

un

ity g

rou

ps e

tc

willin

g t

o e

ng

ag

e

Ta

rge

t a

ud

ien

ce

re

ce

ptive

to n

ew

me

ssa

ge

s e

ve

n if

co

ntr

ary

to

tra

ditio

na

l b

elie

fs

Pri

va

te s

ecto

r w

illin

g t

o

en

ga

ge

, re

ce

ptive

to

28

tra

de

rs/im

po

rte

rs o

f b

rea

st

milk s

ub

stitu

tes

3.1

.9

Co

nd

uct

se

nsitis

atio

n o

n t

he

pri

ncip

les a

nd

aim

s o

f In

tern

atio

na

l co

de

of

Ma

rke

tin

g o

f

Bre

ast

milk S

ub

stitu

tes w

ith

vie

w t

o a

ll p

art

ies

ad

op

tin

g a

nd

sig

nin

g

3.1

.10

D

eve

lop

a r

oa

d m

ap

fo

r th

e d

raft

ing

an

d

imp

lem

en

tatio

n o

f a

lo

ca

l C

od

e o

f M

ark

etin

g o

f

Bre

ast

milk s

ub

stitu

tes

3.2

.1

Co

nd

uct

form

ative

re

se

arc

h t

o a

sse

ss e

na

blin

g

facto

rs a

nd

b

arr

iers

to

o

ptim

al

co

mp

lem

en

tary

fee

din

g p

ractice

s

3.2

.2

De

ve

lop

an

d im

ple

me

nt

a t

rain

ing

pla

n a

nd

cu

rric

ula

fo

r co

mm

un

ity b

ase

d w

ork

ers

an

d

he

alth

fa

cility s

taff

(in

teg

rate

in

to e

xis

tin

g

cu

rric

ula

fo

r C

HW

& M

CH

& T

BA

)

3.2

.3

De

ve

lop

ke

y r

eg

ion

-sp

ecific

me

ssa

ge

s a

nd

recip

es f

or

op

tim

al co

mp

lem

en

tary

fe

ed

ing

pra

ctice

s a

nd

in

teg

rate

with

sim

ple

me

ssa

ge

s

on

fo

od

sa

fety

an

d g

oo

d h

yg

ien

e p

ractice

s

3.2

.4

Dis

se

min

ate

me

ssa

ge

s t

hro

ug

h e

ffe

ctive

de

live

ry m

ech

an

ism

s in

clu

din

g in

div

idu

al

co

un

se

llin

g,

sch

oo

ls,

relig

iou

s/c

om

mu

nity

gro

up

s &

le

ad

ers

an

d m

ass m

ed

ia c

ha

nn

els

3.3

.1

Co

nd

uct

form

ative

re

se

arc

h o

n i

de

ntifica

tio

n o

f

loca

lly

ava

ila

ble

n

utr

ien

t d

en

se

fo

od

s

an

d

ha

bits,

tab

oo

s,

pra

ctice

s

tha

t in

flu

en

ce

th

eir

co

nsu

mp

tio

n

3.3

.2

Ba

se

d o

n a

bo

ve

, d

eve

lop

ke

y m

essa

ge

s a

nd

recip

es t

o p

rom

ote

co

nsu

mp

tio

n o

f a

pp

rop

ria

te

3.1

.9 S

en

sitis

atio

n is c

on

du

cte

d

3.1

.10

Ro

ad

ma

p is d

eve

lop

ed

3.2

.1 E

na

blin

g f

acto

rs a

nd

ba

rrie

rs a

re

ide

ntifie

d

3.2

.2a

Cu

rric

ula

& t

rain

ing

pla

n is

de

ve

lop

ed

3.2

.2b

Nu

mb

er

of

he

alth

wo

rke

rs t

rain

ed

in o

ptim

al co

mp

lem

en

tary

fe

ed

ing

pra

ctice

s

3.2

.3

Me

ssa

ge

s a

nd

re

cip

es a

re

de

ve

lop

ed

3.2

.4 B

CC

im

ple

me

nte

d

3.3

.1 R

ese

arc

h c

on

du

cte

d &

fin

din

gs

dis

se

min

ate

d

3.3

.2 K

ey m

essa

ge

s d

eve

lop

ed

&

dis

se

min

ate

d

Imp

lem

en

tin

g p

art

ne

r

rep

ort

s

Pu

blish

ed

ro

ad

ma

p

Re

se

arc

h r

ep

ort

Re

po

rts

Da

tab

ase

on

tra

ine

d

he

alth

wo

rke

rs

Re

po

rts

Activity r

ep

ort

s

Re

se

arc

h r

ep

ort

Activity r

ep

ort

s

ad

vo

ca

cy

Fin

din

gs a

re r

elia

ble

He

alth

sta

ff a

re m

otiva

ted

to

pro

vid

e c

ou

nse

llin

g

Ta

rge

t a

ud

ien

ce

re

ce

ptive

to n

ew

me

ssa

ge

s e

ve

n if

co

ntr

ary

to

tra

ditio

na

l b

elie

fs

Institu

tio

ns in

th

e

me

ch

an

ism

are

willin

g t

o

acce

pt

ne

w in

no

va

tio

n

Co

mm

un

ity w

illin

g t

o s

ha

re

kn

ow

led

ge

an

d in

form

atio

n

Ta

rge

t a

ud

ien

ce

re

ce

ptive

to n

ew

me

ssa

ge

s e

ve

n if

29 n

utr

ien

t d

en

se

fo

od

s,

inclu

din

g

se

afo

od

a

nd

off

al,

an

d

dis

se

min

ate

to

g

en

era

l p

op

ula

tio

n

thro

ug

h a

pp

rop

ria

te c

om

mu

nity b

ase

d d

elive

ry

ch

an

ne

ls

3.3

.3

Lin

k

with

a

gri

cu

ltu

re/liv

elih

oo

ds

se

cto

r to

pro

mo

te

pro

du

ctio

n

&

utilisa

tio

n

of

loca

lly

ava

ila

ble

nu

trie

nt

de

nse

fo

od

s

3.3

.4

Lin

k

with

a

gri

cu

ltu

re/liv

elih

oo

ds

se

cto

r to

incre

ase

un

de

rsta

nd

ing

an

d u

se

of

ap

pro

pri

ate

foo

d p

rese

rva

tio

n t

ech

niq

ue

s e

sp

ecia

lly o

f m

ilk

an

d m

ilk p

rod

ucts

3.4

.1

Co

nd

uct

form

ative

re

se

arc

h t

o id

en

tify

co

mm

on

pra

ctice

s t

ha

t ca

use

sig

nific

an

t in

hib

itio

n o

f

mic

ron

utr

ien

t a

bso

rptio

n f

rom

die

t

3.4

.2

De

ve

lop

ke

y m

essa

ge

s a

ime

d a

t re

du

cin

g

the

se

pra

ctice

s a

nd

dis

se

min

ate

to

ge

ne

ral

po

pu

latio

n t

hro

ug

h a

pp

rop

ria

te c

om

mu

nity

ba

se

d d

elive

ry c

ha

nn

els

3.5

.1

D

eve

lop

an

d im

ple

me

nt

tra

inin

g p

lan

an

d

cu

rric

ula

on

nu

tritio

n c

ou

nse

llin

g s

kills

fo

r

pre

gn

an

t a

nd

la

cta

tin

g w

om

en

fo

r C

HW

& M

CH

sta

ff

3.5

.2

M

CH

sta

ff p

rovid

e a

pp

rop

ria

te n

utr

itio

n

co

un

se

llin

g (

inclu

din

g lo

ca

l fo

od

de

mo

nstr

atio

ns)

at

an

ten

ata

l a

nd

po

st

na

tal

vis

its

3.5

.3

Co

nd

uct

tria

ls t

o id

en

tify

in

no

va

tive

po

pu

latio

n

ba

se

d d

elive

ry m

ech

an

ism

fo

r n

utr

itio

n

co

un

se

llin

g f

or

pre

gn

an

t a

nd

la

cta

tin

g w

om

en

3.5

.4

E

sta

blish

po

pu

latio

n b

ase

d d

elive

ry

me

ch

an

ism

(in

clu

din

g m

on

ito

rin

g s

yste

m),

pro

vid

ing

tra

inin

g,

tech

nic

al &

ma

teri

al su

pp

ort

3.3

.3

Nu

mb

er

of

inte

r se

cto

r te

ch

nic

al

co

nsu

lta

tio

ns h

eld

3.3

.4

Fo

rum

on

fo

od

pre

se

rva

tio

n

tech

niq

ue

s e

sta

blish

ed

3.4

.1

Re

se

arc

h c

on

du

cte

d &

fin

din

gs

dis

se

min

ate

d

3.4

.2

Ke

y m

essa

ge

s d

eve

lop

ed

&

dis

se

min

ate

d

3.5

.1

Cu

rric

ula

& t

rain

ing

pla

n

de

ve

lop

ed

& im

ple

me

nte

d

3.5

.2

80

% p

reg

na

nt

an

d la

cta

tin

g

wo

me

n a

tte

nd

ing

MC

H r

ece

ive

nu

tritio

n c

ou

nse

llin

g

3.5

.3

Tri

als

co

nd

ucte

d &

de

live

ry

me

ch

an

ism

id

en

tifie

d

3.5

.4

De

live

ry m

ech

an

ism

esta

blish

ed

Re

po

rts

Re

po

rts

Re

se

arc

h r

ep

ort

do

cu

me

nta

tio

n

Da

ta b

ase

on

tra

ine

d

pe

rso

nn

el

HM

IS

Tri

al re

po

rts

Activity r

ep

ort

s

co

ntr

ary

to

tra

ditio

na

l b

elie

fs

Ag

ricu

ltu

re a

nd

liv

elih

oo

ds

se

cto

r re

ce

ptive

to

co

lla

bo

ratio

n

Co

mm

un

ity w

illin

g t

o s

ha

re

kn

ow

led

ge

an

d in

form

atio

n

Ta

rge

t a

ud

ien

ce

re

ce

ptive

to n

ew

me

ssa

ge

s e

ve

n if

co

ntr

ary

to

tra

ditio

na

l b

elie

fs

MC

H s

taff

mo

tiva

ted

to

pro

vid

e c

ou

nse

llin

g

Pre

gn

an

t &

la

cta

tin

g w

om

en

rece

ptive

to

co

un

se

llin

g

30 O

utc

om

e 4

Pro

jec

t d

es

cri

pti

on

Ind

ica

tors

S

ou

rce

of

ve

rifi

ca

tio

n

As

su

mp

tio

ns

Ou

tco

me

4:

Imp

rove

d a

va

ila

bility a

nd

co

ve

rag

e o

f m

icro

nu

trie

nts

an

d d

e-w

orm

ing

in

terv

en

tio

ns t

o t

he

po

pu

latio

n

8 I

ncre

asin

g t

ren

ds in

bi a

nn

ua

l

vita

min

A s

up

ple

me

nta

tio

n in

ch

ild

ren

6-5

9 m

on

ths,

an

d

de

wo

rmin

g c

ove

rag

e in

1-5

ye

ars

,

sch

oo

l a

ge

d c

hild

ren

, p

reg

na

nt

(no

t

1st t

rim

este

r) &

la

cta

tin

g w

om

en

Ba

se

lin

e c

ove

rag

e d

ata

fro

m M

icro

nu

trie

nt

su

rve

y

MIC

S,

FS

NA

U s

urv

ey

rep

ort

s

Acce

ss t

o f

un

ctio

nin

g h

ea

lth

se

rvic

es

Acce

ss t

o f

oo

d s

ecu

rity

Acce

ss t

o h

ea

lth

y e

nvir

on

me

nt

Ou

tpu

ts:

4.1

In

cre

ase

d a

va

ila

bility o

f fo

rtifie

d f

oo

d

4.2

Im

pro

ve

d a

cce

ss t

o a

nd

utilisa

tio

n o

f m

icro

nu

trie

nt

su

pp

lem

en

ts a

nd

fo

rtifie

d su

pp

lem

en

tary

fo

od

b

y

vu

lne

rab

le g

rou

ps,

inclu

din

g u

nd

er

five

s,

pre

gn

an

t

an

d l

acta

tin

g w

om

en

, th

rou

gh

he

alth

se

rvic

es a

nd

co

mm

un

ity b

ase

d d

elive

ry s

tra

teg

ies

4.1

a 2

0%

ce

rea

ls p

rovid

ed

as

hu

ma

nita

ria

n a

ssis

tan

ce

are

fort

ifie

d b

y e

nd

of

thir

d y

ea

r

4.1

b 2

0%

in

cre

ase

in

ava

ila

bility o

f

fort

ifie

d f

oo

d (

no

n h

um

an

ita

ria

n)

by

en

d o

f th

ird

ye

ar

4.2

a a

t le

ast

80

% a

cce

ssib

le

ch

ild

ren

6-5

9 m

on

ths r

ece

ive

d

bi-

an

nu

al V

ita

min

A t

hro

ug

h

CH

D

4.2

b 9

0%

ch

ild

ren

6 t

o 5

9 m

on

ths in

nu

tritio

n p

rog

ram

me

s r

ece

ive

d

vita

min

A d

ose

4.2

c 8

0 %

wo

me

n a

nd

ch

ild

ren

wh

o

acce

ss M

CH

se

rvic

es r

ece

ive

reco

mm

en

de

d m

ultip

le

mic

ron

utr

ien

t su

pp

lem

en

tatio

n

4.2

d N

um

be

r o

f p

reg

na

nt

an

d

lacta

tin

g w

om

en

wh

o r

ece

ive

d

mu

ltip

le m

icro

nu

trie

nt

WF

P d

ata

WF

P d

ata

on

im

po

rts

CH

D r

ep

ort

s/F

SN

AU

nu

tritio

n s

urv

ey r

ep

ort

s

Imp

lem

en

tin

g p

art

ne

r

rep

ort

s

HM

IS

MIC

S

Pro

gra

mm

e d

ata

Co

mm

un

ity w

illin

g t

o a

cce

pt

fort

ifie

d

foo

d

Se

cu

rity

situ

atio

n a

llo

ws a

cce

ss f

or

imp

lem

en

tatio

n a

nd

utilisa

tio

n o

f

se

rvic

es

Mic

ron

utr

ien

t su

pp

lem

en

ts &

fo

rtifie

d

su

pp

lem

en

tary

fo

od

acce

pta

ble

to

targ

et

po

pu

latio

ns

Ta

rge

t p

op

ula

tio

ns c

om

ply

with

su

pp

lem

en

tatio

n r

eg

ime

31

4.3

In

cre

ase

d c

ove

rag

e o

f d

e-w

orm

ing

th

rou

gh

po

pu

latio

n-b

ase

d d

elive

ry m

ech

an

ism

s:

a)

Ch

ild

He

alth

Da

ys,

b)

sch

oo

ls,

c)

MC

H s

erv

ice

s a

nd

d)

nu

tritio

n p

rog

ram

me

s

su

pp

lem

en

tatio

n t

hro

ug

h

co

mm

un

ity b

ase

d d

elive

ry

me

ch

an

ism

4.2

e 9

5%

of

targ

ete

d b

en

eficia

rie

s

rece

ive

d f

ort

ifie

d

su

pp

lem

en

tary

fo

od

4.3

a

>8

0%

acce

ssib

le c

hild

ren

ag

ed

1 t

o 5

ye

ars

re

ce

ivin

g

de

wo

rmin

g t

hro

ug

h C

HD

4.3

b

70

% c

hild

ren

att

en

din

g

sch

oo

l re

ce

ive

de

-wo

rmin

g

4.3

c

40

% e

lig

ible

pre

gn

an

t (n

ot

1st

trim

este

r)a

nd

la

cta

tin

g

wo

me

n a

tte

nd

ing

MC

H

rece

ive

de

wo

rmin

g

4.3

d

90

% e

lig

ible

nu

tritio

n

pro

gra

mm

e b

en

eficia

rie

s

rece

ivin

g d

e-w

orm

ing

Imp

lem

en

tin

g p

art

ne

rs

rep

ort

s

Pro

gra

mm

e e

va

lua

tio

n

da

ta

CH

D r

ep

ort

s

Sch

oo

l re

po

rts o

f d

e-

wo

rmin

g a

ctivitie

s/

pro

gra

mm

e r

ep

ort

s

HM

IS

Imp

lem

en

tin

g p

art

ne

r

rep

ort

s

Activitie

s:

4.1

.1

Fo

rm a

fo

od

fo

rtific

atio

n s

ub

wo

rkin

g g

rou

p o

f

the

nu

tritio

n c

luste

r, w

ith

de

fin

ed

TO

Rs a

nd

me

mb

ers

hip

4.1

.2

Co

mm

issio

n f

oo

d f

ort

ific

atio

n e

xp

ert

fo

r p

eri

od

of

6 m

on

ths

4.1

.3

By e

nd

of

firs

t ye

ar,

co

nd

uct

fea

sib

ility s

tud

y o

f

ho

w f

ort

ific

atio

n o

f ce

rea

l flo

urs

fo

r

hu

ma

nita

ria

n f

oo

d a

ssis

tan

ce

ca

n b

e im

pro

ve

d,

inclu

din

g t

he

de

fin

itio

n o

f ta

rge

ts t

o b

e

ach

ieve

d o

ve

r su

bse

qu

en

t tw

o y

ea

rs

4.1

.4

P

ilo

t p

roje

ct

of

inclu

sio

n o

f fo

rtifie

d c

ere

al flo

urs

in h

um

an

ita

ria

n a

ssis

tan

ce

ge

ne

ral fo

od

ra

tio

n

4.1

.1 F

oo

d f

ort

ific

atio

n s

ub

wo

rkin

g

gro

up

is f

orm

ed

an

d m

ee

ts r

eg

ula

rly

4.1

.2 E

xp

ert

is c

om

mis

sio

ne

d

4.1

.3 F

ea

sib

ility s

tud

y c

on

du

cte

d &

targ

ets

de

fin

ed

4.1

.4

10

0%

ta

rge

ted

po

pu

latio

n

rece

ivin

g f

ort

ifie

d c

ere

al

TO

Rs

Me

etin

g r

ep

ort

s

Re

po

rt

Imp

lem

en

tin

g a

ge

ncie

s

rep

ort

s

Su

ita

ble

ca

nd

ida

te a

va

ila

ble

Su

ffic

ien

t su

pp

lie

s a

nd

lo

gis

tic s

up

po

rt

32 co

nd

ucte

d f

or

a s

pe

cific

ta

rge

t p

op

ula

tio

n

de

fin

ed

by n

utr

itio

n &

fo

od

aid

clu

ste

rs

4.1

.5

De

ve

lop

a f

ram

ew

ork

an

d a

ctio

n p

lan

, in

clu

din

g

reg

ula

tory

me

ch

an

ism

, fo

r th

e f

ort

ific

atio

n o

f

imp

ort

ed

fo

od

th

rou

gh

en

ga

gin

g w

ith

na

tio

na

l

an

d lo

ca

l a

uth

ori

tie

s a

nd

pri

va

te s

ecto

r

4.1

.6

Imp

lem

en

t a

ctio

n p

lan

fo

r fo

rtific

atio

n o

f

imp

ort

ed

fo

od

4.1

.7

Exp

lore

th

e p

ote

ntia

l fo

r fo

rtific

atio

n o

f lo

ca

l

ava

ilab

le f

oo

d t

hro

ug

h e

ng

ag

ing

with

lo

ca

l a

nd

na

tio

na

l a

uth

ori

tie

s a

nd

pri

va

te s

ecto

r d

uri

ng

ye

ar

1

4.1

.8

Co

nd

uct

inve

stig

atio

n in

to io

din

e s

itu

atio

n in

co

un

try

4.2

.1

Pro

vid

e t

rain

ing

, su

pp

lies a

nd

mo

nito

rin

g in

pu

t

to im

pro

ve

dis

trib

utio

n o

f vita

min

A

su

pp

lem

en

ts t

o a

ll ch

ildre

n 6

-5

9 m

on

ths

thro

ug

h b

i-a

nn

ua

l ch

ild h

ea

lth

da

ys

4.2

.2

D

eve

lop

sim

ple

So

ma

lia s

pe

cific

sta

nd

ard

ise

d

pro

toco

ls f

or

mic

ron

utr

ien

t su

pp

lem

en

tatio

n f

or

pre

gn

an

t &

la

cta

tin

g w

om

en

4.2

.3

D

eve

lop

an

d im

ple

me

nt

cu

rric

ula

an

d t

rain

ing

pla

n f

or

CH

W a

nd

MC

H s

taff

on

mic

ron

utr

ien

t

su

pp

lem

en

tatio

n

4.2

.4

P

rovid

e m

icro

nu

trie

nt

su

pp

lem

en

tatio

n s

up

plie

s

on

tim

ely

ba

sis

4.2

.5

M

CH

sta

ff p

rovid

e a

pp

rop

ria

te m

icro

nu

trie

nt

su

pp

lem

en

tatio

n a

t a

nte

na

tal a

nd

po

st

na

tal

vis

its

flo

urs

in

hu

ma

nita

ria

n

assis

tan

ce

ge

ne

ral fo

od

ratio

n

4.1

.5

Fra

me

wo

rk,

actio

n p

lan

an

d

reg

ula

tory

me

ch

an

ism

de

ve

lop

ed

4.1

.6

95

% a

ctio

n p

oin

ts o

f p

lan

imp

lem

en

ted

4.1

.7

Po

ten

tia

l fo

r lo

ca

l fo

rtific

atio

n

is d

efin

ed

4.1

.8 I

nve

stig

atio

n is c

on

du

cte

d

4.2

.1a

> 9

0%

CH

D w

ork

ers

tra

ine

d,

4.2

.1b

>9

0%

re

qu

ire

d s

up

plie

s

pro

vid

ed

4.2

.1c >

95

% m

on

ito

rin

g t

arg

ets

me

t

4.2

.2

sta

nd

ard

ise

d p

roto

co

l

de

ve

lop

ed

4.2

.3

Nu

mb

er

of

CH

W a

nd

MC

H

sta

ff t

rain

ed

on

mic

ron

utr

ien

t

su

pp

lem

en

tatio

n

4.2

.4

Nu

mb

er

of

da

ys s

tock o

uts

4.2

.5

80

% p

reg

na

nt

an

d la

cta

tin

g

wo

me

n a

tte

nd

ing

MC

H

rece

ivin

g m

icro

nu

trie

nt

su

pp

lem

en

tatio

n

Do

cu

me

nta

tio

n

Re

vie

w o

f a

ctivitie

s

Re

po

rt

Do

cu

me

nta

tio

n

CH

D e

va

lua

tio

n r

ep

ort

s

Do

cu

me

nta

tio

n

Ne

w d

ata

ba

se

on

tra

inin

g

rece

ive

d b

y h

ea

lth

wo

rke

rs

HM

IS

HM

IS

Will

ing

ne

ss o

f p

riva

te s

ecto

r to

en

ga

ge

an

d c

o-o

pe

rate

Fin

an

cia

l a

nd

ma

teri

al re

so

urc

es

ava

ilab

le

Inte

rest

an

d s

up

po

rt in

fo

od

fo

rtific

atio

n

fro

m lo

ca

l a

nd

na

tio

na

l a

uth

ori

tie

s

CH

D w

ork

ers

mo

tiva

ted

He

alth

wo

rke

rs m

otiva

ted

to

pro

vid

e

mic

ron

utr

ien

t su

pp

lem

en

tatio

n

Su

ffic

ien

t re

so

urc

es &

eff

icie

nt

log

istica

l

su

pp

ort

ava

ilab

le

Institu

tio

ns/g

rou

ps id

en

tifie

d w

illin

g a

nd

acce

ptin

g o

f in

vo

lve

me

nt

33

4.2

.6

Co

nd

uct

tria

ls t

o id

en

tify

in

no

va

tive

po

pu

latio

n

ba

se

d d

eliv

ery

me

ch

an

ism

s f

or

mu

ltip

le

mic

ron

utr

ien

t su

pp

lem

en

tatio

n t

o w

om

en

of

rep

rod

uctive

ag

e

4.2

.7

Ba

se

d o

n t

ria

ls,

sca

le u

p p

op

ula

tio

n b

ase

d

de

live

ry m

ech

an

ism

fo

r m

ultip

le m

icro

nu

trie

nt

su

pp

lem

en

tatio

n,

inclu

din

g p

roto

co

l

de

ve

lop

me

nt,

tra

inin

g,

su

pp

lies a

nd

mo

nito

rin

g

syste

m

4.2

.8

Co

nd

uct

fea

sib

ility

stu

dy o

f h

om

e f

ort

ific

atio

n

pro

du

cts

, d

efin

ing

ta

rge

ts a

nd

actio

n p

lan

fo

r

su

bse

qu

en

t im

ple

me

nta

tio

n

4.2

.9

Imp

lem

en

t a

ctio

n p

lan

on

ho

me

fo

rtific

atio

n

pro

du

cts

acco

rdin

g t

o f

ea

sib

ility

stu

dy

reco

mm

en

da

tio

ns

4.2

.10

D

istr

ibu

te f

ort

ifie

d s

up

ple

me

nta

ry f

oo

ds t

o

vu

lne

rab

le g

rou

ps in

se

lecte

d h

igh

ris

k a

rea

s

as d

efin

ed

by n

utr

itio

n c

luste

r

4.3

.1

Pro

vid

e t

rain

ing

, su

pp

lies a

nd

mo

nito

rin

g i

np

ut

for

de

wo

rmin

g to

b

i a

nn

ua

l C

HD

s &

n

utr

itio

n

pro

gra

mm

es

4.3

.2

De

ve

lop

sim

ple

, S

om

ali

sp

ecific

pro

toco

l fo

r

de

wo

rmin

g in

sch

oo

ls,

inclu

din

g s

yste

m f

or

mo

nito

rin

g &

eva

lua

tio

n

4.3

.3

Pro

vid

e t

ech

nic

al (W

HO

) &

lo

gis

tica

l (W

FP

)

su

pp

ort

to

sch

oo

ls d

ew

orm

ing

pro

gra

mm

e

4.3

.4

De

ve

lop

sim

ple

pro

toco

l fo

r d

ew

orm

ing

of

pre

gn

an

t &

la

cta

tin

g w

om

en

an

d c

hild

ren

1-5

ye

ars

at

MC

H f

acili

tie

s &

He

ath

po

sts

, a

ime

d a

t

4.2

.6

Po

pu

latio

n b

ase

d d

eliv

ery

me

ch

an

ism

id

en

tifie

d b

y e

nd

of

ph

ase

1

4.2

.7

De

live

ry m

ech

an

ism

fo

r

mu

ltip

le m

icro

nu

trie

nt

su

pp

lem

en

tatio

n is

esta

blis

he

d in

se

lecte

d

are

as,

by e

nd

ph

ase

2

4.2

.8

Fe

asib

ility

stu

dy is

co

nd

ucte

d,

targ

ets

se

t,

actio

n p

lan

de

fin

ed

, b

y e

nd

of

ph

ase

1

4.2

.9

Actio

n p

lan

im

ple

me

nte

d in

se

lecte

d a

rea

s,

by e

nd

of

ph

ase

2

4.2

.10

75

% t

arg

ete

d b

en

eficia

rie

s

rea

ch

ed

4.3

.1a

9

5%

CH

D w

ork

ers

tra

ine

d,

4.3

.1b

95

% r

eq

uir

ed

su

pp

lies

pro

vid

ed

4.3

.1c 9

5%

mo

nito

rin

g t

arg

ets

me

t

4.3

.2 a

) P

roto

co

l is

de

ve

lop

ed

b)

incre

asin

g t

ren

ds in

x%

sch

oo

ls

imp

lem

en

tin

g p

roto

co

l9

4.3

.3 9

0%

ta

rge

ted

sch

oo

ls r

ece

ive

de

fin

ed

su

pp

ort

4.3

.4a

Pro

toco

l is

de

ve

lop

ed

4.3

.4b

in

cre

asin

g t

ren

ds in

x%

he

alth

fa

cili

tie

s im

ple

me

ntin

g

Activity r

ep

ort

s

Tri

al re

po

rts

Imp

lem

en

tin

g a

ge

ncie

s

rep

ort

s

Stu

dy r

ep

ort

Activity r

ep

ort

s

Imp

lem

en

tin

g a

ge

ncie

s

rep

ort

s

CH

D &

nu

tritio

n

pro

gra

mm

e r

ep

ort

s

Do

cu

me

nta

tio

n

Sch

oo

l, W

HO

, W

FP

rep

ort

s

Do

cu

me

nta

tio

n

Fa

cili

ty s

urv

ey d

ata

Su

ffic

ien

t re

so

urc

es &

eff

icie

nt

log

istica

l

su

pp

ort

ava

ilab

le

Ta

rge

ted

be

ne

ficia

rie

s w

illin

g t

o u

se

ne

w m

ech

an

ism

Ho

me

fo

rtific

atio

n p

rod

ucts

acce

pta

ble

to b

en

eficia

rie

s

Ta

rge

ted

be

ne

ficia

rie

s u

se

su

pp

lem

en

tary

fo

od

s a

s in

str

ucte

d

CH

D &

nu

tritio

n p

rog

ram

me

wo

rke

rs

mo

tiva

ted

to

pro

vid

e d

ew

orm

ing

Sch

oo

ls r

ece

ptive

an

d w

illin

g t

o

imp

lem

en

t d

ew

orm

ing

He

alth

sta

ff m

otiva

ted

to

im

ple

me

nt

pro

toco

l

Su

ffic

ien

t su

pp

lies a

nd

eff

icie

nt

log

istica

l su

pp

ort

34

red

ucin

g m

isse

d o

pp

ort

un

itie

s

4.3

.5

Pro

vid

e t

rain

ing

& t

ime

ly s

up

plie

s t

o C

HW

&

MC

H s

taff

fo

r e

ffe

ctive

im

ple

me

nta

tio

n o

f

de

wo

rmin

g p

roto

co

l

de

wo

rmin

g p

roto

co

l10

4.3

.5a

Nu

mb

er

of

he

alth

sta

ff

tra

ine

d a

nd

active

on

de

wo

rmin

g

4.3

.5b

Nu

mb

er

of

da

ys o

f sto

ck o

uts

of

de

wo

rmin

g d

rug

s

Ne

w d

ata

ba

se

on

tra

inin

g

of

he

alth

wo

rke

rs

HM

IS S

up

ply

da

ta

35 O

utc

om

e 5

Pro

jec

t d

es

cri

pti

on

Ind

ica

tors

S

ou

rce

of

ve

rifi

ca

tio

n

As

su

mp

tio

ns

Ou

tco

me

5:

Imp

rove

d m

ain

str

ea

min

g o

f n

utr

itio

n a

s a

ke

y

co

mp

on

en

t o

f h

ea

lth

an

d o

the

r re

leva

nt

se

cto

rs

70

% h

ea

lth

, W

AS

H,

live

lih

oo

d,

ed

uca

tio

n a

nd

fo

od

aid

CA

P

pro

jects

in

clu

de

nu

tritio

n in

dic

ato

rs

50

% o

f h

ea

lth

, W

AS

H,

Liv

elih

oo

d,

ed

uca

tio

n s

ecto

r p

roje

cts

in

clu

de

nu

tritio

n a

ctivitie

s

Nu

tritio

n a

ctivitie

s/o

utc

om

es a

re

inclu

de

d in

UN

SA

S

CA

P r

evie

w

3W

s o

f se

cto

r clu

ste

rs

an

d w

ork

ing

gro

up

s

UN

SA

S r

evie

w

Ou

tpu

ts:

5.1

Nu

tritio

n is e

ffe

ctive

ly in

co

rpo

rate

d in

to t

he

po

licie

s,

str

ate

gie

s,

activitie

s,

de

live

ry

me

ch

an

ism

s

an

d

ou

tco

me

s o

f h

ea

lth

se

cto

r

5.1

a n

um

be

r o

f re

leva

nt

he

alth

se

cto

r p

olicie

s e

tc in

clu

din

g n

utr

itio

n

ind

ica

tors

5.1

b 6

0%

11 w

om

en

an

d c

hild

ren

att

en

din

g M

CH

se

rvic

es w

ho

rece

ive

ap

pro

pri

ate

nu

tritio

n

scre

en

ing

, n

utr

itio

n c

ou

nse

llin

g &

mic

ron

utr

ien

t tr

ea

tme

nt

or

su

pp

lem

en

tatio

n b

y e

nd

of

firs

t

ph

ase

, in

cre

asin

g t

o 8

0%

by e

nd

of

ph

ase

2

5.1

c >

80

% t

arg

ete

d b

en

eficia

rie

s o

f

CH

D r

ece

ivin

g v

ita

min

A,

nu

tritio

n

scre

en

ing

& d

ew

orm

ing

5.1

d N

utr

itio

n in

terv

en

tio

ns a

re

inclu

de

d a

s c

ore

co

mp

on

en

t in

Re

vie

w o

f p

olicy,

str

ate

gy a

ctivity

do

cu

me

nts

HM

IS

CH

D e

va

lua

tio

n r

ep

ort

s

Re

vie

w o

f p

olicie

s a

nd

pro

gra

mm

es

Willin

gn

ess o

f o

the

r se

cto

rs t

o

co

lla

bo

rate

36 5

.2 N

utr

itio

n is

in

teg

rate

d in

to th

e p

olicie

s,

str

ate

gie

s,

activitie

s,

de

live

ry

me

ch

an

ism

s

an

d

ou

tco

me

s

of

WA

SH

, live

lih

oo

ds,

ed

uca

tio

n a

nd

fo

od

aid

se

cto

rs

ma

na

ge

me

nt

of

rele

va

nt

co

mm

un

ica

ble

an

d n

on

co

mm

un

ica

ble

dis

ea

se

s e

g T

B,

HIV

, m

ala

ria

, m

en

tal h

ea

lth

5.2

a W

AS

H

50

% o

f re

leva

nt

WA

SH

inte

rve

ntio

ns in

clu

de

nu

tritio

n

ind

ica

tors

as m

ea

su

re o

f im

pa

ct

75

% n

utr

itio

n p

rog

ram

me

s

de

live

rin

g g

oo

d h

yg

ien

e p

rom

otio

n

activitie

s

5.2

b A

gri

cu

ltu

re/L

ive

lih

oo

ds

70

% r

ele

va

nt

pro

jects

in

co

rpo

ratin

g

nu

tritio

n in

dic

ato

rs a

s o

utc

om

e

ind

ica

tors

,

70

% r

ele

va

nt

pro

jects

use

nu

tritio

n

sta

tus f

or

targ

etin

g in

terv

en

tio

ns

70

% r

ele

va

nt

pro

jects

in

clu

de

nu

tritio

n e

du

ca

tio

n a

s a

su

pp

ort

ing

activity

5.2

c E

du

ca

tio

n

70

% s

ch

oo

ls p

rovid

e n

utr

itio

n

ed

uca

tio

n a

s p

art

of

reg

ula

r

cu

rric

ulu

m

Re

vie

w o

f p

olicie

s a

nd

pro

jects

Re

vie

w o

f p

olicie

s a

nd

pro

jects

Re

vie

w o

f cu

rric

ula

Sch

oo

l re

po

rts

Willin

gn

ess o

f h

ea

lth

se

cto

r to

co

lla

bo

rate

Su

ffic

ien

t re

so

urc

es a

va

ila

ble

Activitie

s:

5.1

.1

Fo

ste

r im

pro

ve

d

inte

rse

cto

ral

co

lla

bo

ratio

n

&

de

fin

e p

rio

rity

are

as f

or

pa

rtn

ers

hip

5.1

.1a

nu

mb

er

of

inte

rse

cto

ral

co

nsu

lta

tio

n m

ee

tin

gs h

eld

5.1

.1b

x%

att

en

da

nce

at

se

cto

r

clu

ste

r m

ee

tin

gs

12

Me

etin

g r

ep

ort

s

Willin

gn

ess o

f o

the

r se

cto

rs t

o

co

lla

bo

rate

37

5.1

.2

Esta

blish

m

ech

an

ism

fo

r te

ch

nic

al

nu

tritio

n

inp

ut

into

re

leva

nt

me

etin

gs,

revie

ws

5.1

.3

Pro

vid

e

ne

ce

ssa

ry

inp

uts

(f

un

din

g,

tra

inin

g,

su

pp

lie

s,

mo

nito

rin

g)

to

imp

rove

q

ua

lity

o

f

nu

tritio

n

se

rvic

es

de

live

red

th

rou

gh

C

HD

s,

acco

rdin

g t

o d

efin

ed

ta

rge

ts

5.1

.4

Pro

vid

e

ne

ce

ssa

ry

inp

uts

to

im

pro

ve

q

ua

lity

an

d

co

ve

rag

e

of

nu

tritio

n

se

rvic

es

de

live

red

thro

ug

h h

ea

lth

fa

cilitie

s (

sta

nd

ard

ise

d g

uid

elin

es

an

d

pro

toco

ls

for

nu

tritio

n

activitie

s,

su

pp

lie

s,

co

mp

reh

en

siv

e t

rain

ing

fo

r h

ea

lth

fa

cility s

taff

)

5.1

.5

Co

nd

uct

ma

pp

ing

of

are

as w

ith

po

or

acce

ss t

o

he

alth

se

rvic

es

5.1

.6

Ad

vo

ca

te

in

loca

tio

ns

wh

ere

a

va

ila

bility

of

he

alth

se

rvic

es

is

a

lim

itin

g

facto

r fo

r o

ptim

al

nu

tritio

n

5.1

.7

Co

nd

uct

se

nsitis

atio

n

on

n

utr

itio

n

as

de

term

ina

nt

of

he

alth

a

nd

d

eve

lop

me

nt

am

on

g

lin

e

min

istr

ies

an

d

ad

vo

ca

te

for

inclu

sio

n

of

nu

tritio

n

inte

rve

ntio

ns

as

co

re

co

mp

on

en

t o

f

pu

blic s

erv

ice

s

5.2

.1

Fo

ste

r in

ters

ecto

ral

co

lla

bo

ratio

n

an

d

de

fin

e

pri

ori

ty a

rea

s fo

r p

art

ne

rsh

ip w

ith

e

ach

se

cto

r

(eg

a

gri

cu

ltu

re/liv

elih

oo

ds-

imp

rovin

g

die

tary

div

ers

ity,

WA

SH

: B

CC

- in

teg

ratin

g p

rom

otio

n o

f

op

tim

al

nu

tritio

n a

nd

g

oo

d h

yg

ien

e p

ractice

s,

ed

uca

tio

n-

inte

gra

tin

g

nu

tritio

n

ed

uca

tio

n

into

sch

oo

l cu

rric

ula

)

5.1

.2 m

ech

an

ism

esta

blish

ed

5.1

.3 9

0%

in

pu

ts p

rovid

ed

,

acco

rdin

g t

o d

efin

ed

ta

rge

ts

5.1

.4a

x%

he

alth

fa

cilitie

s u

sin

g

sta

nd

ard

ise

d

gu

ide

lin

es/p

roto

co

ls13

5.1

.4b

Nu

mb

er

of

da

ys s

tock o

uts

of

nu

tritio

n s

up

plie

s

5.1

.4c x

% h

ea

lth

fa

cility s

taff

rece

ive

d n

utr

itio

n t

rain

ing

14

5.1

.5 M

ap

pin

g c

on

du

cte

d a

nd

do

cu

me

nte

d

5.1

.6 N

um

be

r o

f a

dvo

ca

cy m

ee

tin

gs

he

ld

5.1

.7

Nu

mb

er

of

me

etin

gs h

eld

to

dis

cu

ss n

utr

itio

n w

ith

lin

e

min

istr

ies

5.2

.1a

nu

mb

er

of

inte

rse

cto

ral

co

nsu

lta

tio

n m

ee

tin

gs h

eld

,

5.2

.1b

x%

att

en

da

nce

at

se

cto

r

clu

ste

r m

ee

tin

gs

15

5.2

.1c P

rio

rity

are

as d

efin

ed

Re

po

rts

CH

D e

va

lua

tio

n r

ep

ort

s

HM

IS

Fa

cility b

ase

d s

urv

ey

HM

IS S

up

ply

da

ta

Da

tab

ase

on

tra

ine

d

he

alth

pe

rso

nn

el

Re

po

rts

Me

etin

g r

ep

ort

s

Me

etin

g r

ep

ort

s

Re

po

rts

Su

ffic

ien

t su

pp

lie

s &

lo

gis

tica

l

su

pp

ort

to

im

ple

me

nt

CH

Ds

eff

ective

ly

He

alth

fa

cility s

taff

mo

tiva

ted

to

imp

lem

en

t n

utr

itio

n a

ctivitie

s

Se

cto

r o

pe

n t

o a

dvo

ca

cy

Su

ffic

ien

t re

so

urc

es a

va

ila

ble

Willin

gn

ess o

f o

the

r se

cto

rs t

o

co

lla

bo

rate

38

5.2

.2

Esta

blis

h a

m

ech

an

ism

fo

r te

ch

nic

al

nu

tritio

n

inp

ut

into

re

leva

nt

pro

ce

ss

5.2

.3

Pro

vid

e t

ech

nic

al

inp

ut,

tra

inin

g a

nd

ma

teri

als

for

imp

rovin

g n

utr

itio

n co

mp

on

en

t o

f re

leva

nt

se

cto

r p

rog

ram

min

g,

acco

rdin

g

to

ag

ree

d

targ

ets

5.2

.4

Co

nd

uct

ma

pp

ing

of

are

as w

ith

po

or

acce

ss t

o

WA

SH

/ a

gri

cu

ltu

re/liv

elih

oo

ds/e

du

ca

tio

n

/fo

od

aid

se

rvic

es

5.2

.5

Ad

vo

ca

te

in

loca

tio

ns

wh

ere

a

va

ilab

ility

o

f

WA

SH

/ag

ricu

ltu

re/liv

elih

oo

ds/e

du

ca

tio

n/f

oo

d

aid

se

rvic

es

are

a

lim

itin

g

facto

r fo

r o

ptim

al

nu

tritio

n

5.2

.2 M

ech

an

ism

esta

blis

he

d

5.2

.3a

Nu

mb

er

of

tech

nic

al

co

nsu

lta

tio

ns h

eld

5.2

.3b

>9

0%

ag

ree

d m

ate

ria

ls

su

pp

lied

5.2

.3c 9

0%

ag

ree

d t

rain

ing

s h

eld

5.2

.4

Ma

pp

ing

co

nd

ucte

d

5.2

.5 N

um

be

r o

f a

dvo

ca

cy m

ee

tin

gs

he

ld

Re

po

rt

Co

nsu

lta

tio

n r

ep

ort

s

Pro

gra

mm

e r

ep

ort

s

Pro

gra

mm

e r

ep

ort

s

Do

cu

me

nta

tio

n

Me

etin

g r

ep

ort

s

39

Ou

tco

me

6

Pro

jec

t d

es

cri

pti

on

Ind

ica

tors

S

ou

rce

of

ve

rifi

ca

tio

n

As

su

mp

tio

ns

Ou

tco

me

6:

Imp

rove

d c

ap

acity a

nd

me

an

s in

co

un

try t

o d

eliv

er

esse

ntia

l n

utr

itio

n s

erv

ice

s

Fe

ed

ing

pro

gra

mm

e p

erf

orm

an

ce

ind

ica

tors

as a

me

asu

re o

f ca

pa

city

of

LN

GO

s t

o d

eliv

er

tre

atm

en

t

Incre

asin

g t

ren

d in

nu

mb

er

of

Mo

H

pe

rso

nn

el tr

ain

ed

in

nu

tritio

n

Incre

asin

g t

ren

d in

nu

mb

er

he

alth

facili

tie

s w

ith

pe

rso

nn

el tr

ain

ed

in

nu

tritio

n

Activitie

s o

f lo

ca

l e

sta

blis

he

d

str

uctu

re –

de

ve

lop

se

t o

f

pe

rfo

rma

nce

in

dic

ato

rs a

s p

art

of

TO

Rs

UN

ICE

F d

ata

ba

se

Mo

H r

ep

ort

s

Da

tab

ase

on

he

alth

wo

rke

rs a

nd

tra

inin

g

rece

ive

d

Activity r

ep

ort

s

Se

cu

rity

situ

atio

n a

llow

s d

eliv

ery

of

se

rvic

es

Ou

tpu

ts:

6.1

A tw

o ye

ar

nu

tritio

n se

cto

r ca

pa

city d

eve

lop

me

nt

str

ate

gy a

nd

pla

n o

f a

ctio

n is d

eve

lop

ed

jo

intly w

ith

loca

l a

uth

ori

tie

s b

y t

he

en

d o

f 2

01

1

6.2

Ca

pa

city

de

ve

lop

me

nt

an

d

tra

inin

g

activitie

s

are

imp

lem

en

ted

acco

rdin

g t

o p

lan

of

actio

n

6.3

Re

gio

na

l tr

ain

ing

a

nd

m

en

tori

ng

ce

lls a

re fo

rme

d

by t

he

en

d o

f 2

01

1.

6.4

In

tern

atio

na

lly

reco

gn

ise

d

tra

inin

g

gu

ide

line

s

an

d

pro

toco

ls a

re a

da

pte

d t

o t

he

So

ma

li co

nte

xt

6.5

An

e

na

blin

g

en

vir

on

me

nt

for

all

sta

ke

ho

lde

rs

to

6.1

Str

ate

gy a

nd

actio

n p

lan

is

de

ve

lop

ed

6.2

x%

of

activitie

s d

efin

ed

in

actio

n

pla

n a

re im

ple

me

nte

d1

6

6.3

Ce

lls a

re e

sta

blis

he

d

6.4

a 9

0%

of

rele

va

nt

gu

ide

line

s a

nd

pro

toco

ls a

da

pte

d t

o S

om

ali

co

nte

xt

6.4

b 8

0%

pa

rtn

ers

usin

g a

da

pte

d

gu

ide

line

s b

y e

nd

ph

ase

2

Re

po

rts

Pu

blis

he

d s

tra

teg

y

Re

po

rts

Re

vie

w o

f d

ocu

me

nts

Pa

rtn

ers

re

po

rts

Sta

ke

ho

lde

r re

po

rts

He

alth

au

tho

ritie

s,

line

min

istr

ies

are

su

pp

ort

ive

an

d p

rovid

e

ne

ce

ssa

ry c

on

ditio

ns f

or

imp

lem

en

tatio

n

Re

so

urc

es f

or

ca

pa

city

de

ve

lop

me

nt

str

ate

gy a

re

fort

hco

min

g

Ne

w t

rain

ing

& m

en

tori

ng

ce

lls

acce

pte

d a

nd

giv

en

su

ffic

ien

t

ma

nd

ate

imp

lem

en

t q

ua

lity

nu

tritio

n p

rog

ram

me

s i

s c

rea

ted

an

d

su

sta

ine

d

in

co

lla

bo

ratio

n

with

th

e

loca

l

au

tho

ritie

s

6.5

90

% o

f ta

rge

ted

sta

ke

ho

lde

rs

rece

ivin

g n

ece

ssa

ry

eq

uip

me

nt,

ma

teri

als

an

d

reso

urc

es,

acco

rdin

g t

o a

sta

nd

ard

ize

d a

nd

acce

pte

d lis

t

of

ma

teri

als

ie

co

mp

ute

r,

inte

rne

t co

nn

ectio

n,

ph

oto

co

pie

r e

tc.

an

d a

ge

ncie

s s

up

ply

da

ta

Su

ffic

ien

t re

so

urc

es a

va

ila

ble

Activitie

s:

6.1

.1

Esta

blish

str

ate

gy

de

ve

lop

me

nt

wo

rkin

g

gro

up

with

de

fin

ed

TO

Rs

6.1

.2

Ide

ntify

sco

pe

of

str

ate

gy

6.1

.3

En

su

re m

ulti fa

ce

ted

ap

pro

ach

to

de

ve

lop

me

nt

of

tech

nic

al

skills

–

h

an

ds o

n tr

ain

ing

, w

ork

sh

op

s,

dis

tan

ce

le

arn

ing

o

pp

ort

un

itie

s,

reg

ion

al

vis

its

an

d

wo

rksh

op

s,

ap

pro

pri

ate

n

utr

itio

n

tra

inin

g

inte

gra

ted

in

to

exis

tin

g

pre

-se

rvic

e

tra

inin

g

cu

rric

ula

6.1

.4

C

rea

te

lin

ks

with

re

gio

na

l tr

ain

ing

/me

nto

rin

g

ce

lls,

inte

rna

tio

na

l a

ca

de

mic

/tra

inin

g

institu

tio

ns

6.1

.5

Ad

vo

ca

te f

or

an

d id

en

tify

fu

nd

ing

of

str

ate

gy

6.2

.1

Pro

vid

e

ne

ce

ssa

ry

su

pp

ort

a

nd

in

pu

ts

for

imp

lem

en

tatio

n o

f p

lan

of

actio

n

6.3

.1

De

fin

e s

co

pe

an

d r

ole

of

reg

ion

al

tra

inin

g a

nd

me

nto

rin

g c

ells

6.3

.2

Esta

blish

le

ad

ers

hip

an

d m

em

be

rsh

ip

6.3

.3

Ide

ntify

ga

ps a

nd

tra

inin

g n

ee

ds

6.1

.1 W

ork

ing

gro

up

esta

blish

ed

&

TO

Rs

6.1

.2 S

co

pe

de

fin

ed

6.1

.3 M

ulti fa

ce

ted

ap

pro

ach

ad

op

ted

6.1

.4 n

um

be

r o

f lin

ks e

sta

blish

ed

6.1

.5 x

% f

un

din

g id

en

tifie

d1

7

6.2

.1 9

0%

in

pu

ts p

rovid

ed

acco

rdin

g t

o p

lan

of

actio

n

6.3

.1 T

OR

s d

efin

ed

& a

gre

ed

6.3

.2 L

ea

de

rsh

ip a

nd

me

mb

ers

hip

en

do

rse

d

6.3

.3 G

ap

s a

nd

tra

inin

g n

ee

ds

ide

ntifie

d

Do

cu

me

nta

tio

n

Do

cu

me

nta

tio

n

Re

vie

w o

f str

ate

gy

Do

cu

me

nta

tio

n

Do

cu

me

nta

tio

n

Do

cu

me

nta

tio

n

Ce

ll r

ep

ort

Ce

ll r

ep

ort

Do

cu

me

nta

tio

n

Activity r

ep

ort

s

Wo

rkin

g g

rou

p m

em

be

rs

mo

tiva

ted

Do

no

rs a

re r

ece

ptive

Su

ffic

ien

t re

so

urc

es a

va

ila

ble

He

alth

au

tho

ritie

s,

lin

e m

inis

trie

s

are

su

pp

ort

ive

an

d p

rovid

e

ne

ce

ssa

ry c

on

ditio

ns f

or

esta

blish

me

nt

of

ce

lls

Pa

rtn

ers

/ag

en

cie

s w

illin

g t

o

40

41

6.3

.4

De

ve

lop

a

nd

im

ple

me

nt

tra

inin

g

pla

n

an

d

cu

rric

ula

6.4

.1

Co

nstr

uct

an

in

ve

nto

ry

of

inte

rna

tio

na

lly

reco

gn

ise

d t

rain

ing

gu

ide

line

s a

nd

pro

toco

ls

6.4

.2

Ad

ap

t a

nd

tr

an

sla

te

the

m

ost

rele

va

nt

gu

ide

line

s &

pro

toco

ls t

o t

he

So

ma

li co

nte

xt

6.5

.1

Pro

vid

e

ne

ce

ssa

ry

tra

inin

g,

eq

uip

me

nt,

ma

teri

als

a

nd

re

so

urc

es

to

pa

rtn

ers

imp

lem

en

tin

g

nu

tritio

n

activitie

s,

inclu

din

g

Mo

H,

line

m

inis

trie

s,

LN

GO

s

an

d

co

mm

un

ity

institu

tio

ns

to

en

ab

le

the

m

to

imp

lem

en

t

nu

tritio

n

inte

rve

ntio

ns

acco

rdin

g

to

sta

nd

ard

ise

d g

uid

elin

es

6.3

.4a

cu

rric

ula

de

ve

lop

ed

by e

nd

ph

ase

1

6.3

.4b

80

% t

rain

ing

pla

n

imp

lem

en

ted

by e

nd

ph

ase

2

6.4

.1 in

ve

nto

ry c

om

plie

d

6.4

.2 9

0%

re

leva

nt

gu

ide

line

s &

pro

toco

ls a

da

pte

d &

tra

nsla

ted

6.5

.1 9

0%

re

so

urc

es p

rovid

ed

acco

rdin

g t

o g

uid

elin

es

Re

po

rt

Re

vie

w o

f d

ocu

me

nts

Su

pp

ly d

ata

acce

pt

an

d s

up

po

rt t

he

co

nce

pt

of

tra

inin

g a

nd

me

nto

rin

g c

ells

Ad

ap

tatio

ns a

re a

cce

pta

ble

an

d

ad

op

ted

by a

ge

ncie

s

Imp

lem

en

tin

g p

art

ne

r sta

ff

mo

tiva

ted

to

im

ple

me

nt

activitie

s

1 A

data

base

of

all

healt

h c

are

pro

vid

ers

an

d t

he t

rain

ing

th

ey

hav

e r

eceiv

ed

is

cu

rren

tly

bein

g d

ev

elo

ped

2 I

f in

clu

ded

in

th

e n

ew

MA

M g

uid

eli

nes

3 %

to

be c

on

firm

ed

4 %

to

be c

on

firm

ed

5 R

efe

ren

ce M

icro

nu

trie

nt

surv

ey

20

09

6 R

efe

ren

ce M

ICS

20

06

(re

vis

e a

fter

MIC

S 2

01

0)

7 R

efe

ren

ce M

icro

nu

trie

nt

Su

rvey

20

09

8 I

deall

y o

utc

om

e i

nd

icato

r w

ou

ld b

e i

mp

rov

ed

mic

ron

utr

ien

t st

atu

s o

f p

op

ula

tio

n,

red

uced

pre

vale

nce o

f an

aem

ia,

vit

am

in A

& i

od

ine d

efi

cie

ncy

bu

t 3

years

to

o s

ho

rt t

o

measu

re s

ign

ific

an

t ch

an

ges

& a

s y

et

no

pla

n f

or

rep

eat

mic

ron

utr

ien

t su

rvey

9 %

to

be c

on

firm

ed

1

0 %

to

be c

on

firm

ed

1

1 B

ase

d o

n E

PH

S f

or

So

mali

a 2

00

8

12 %

to

be c

on

firm

ed

1

3 %

to

be c

on

firm

ed

1

4 %

to

be c

on

firm

ed

1

5 %

to

be c

on

firm

ed

1

6 %

to

be c

on

firm

ed

1

7 %

to

be c

on

firm

ed

42

CONTENTS1. Background information 43

2. Current nutrition situation 43 2.1 Acute malnutrition . 43 2.2 Chronic malnutrition. 44 2.3 Trends in malnutrition 2001-2008 44 2.4 Micronutrient malnutrition 45

3. Determinants of malnutrition in Somalia 46 3.1 Food access and availability 46 3.2 Social and care environment . 49 3.3 Access to health services and a healthy environment 51 3.4 Education 52

4. Current Nutrition interventions 52 4.1 Nutrition Cluster approach 52 4.2 Food security and nutrition surveillance 53 4.3 Treatment of severe acute malnutrition 53 4.4 Treatment of moderate acute malnutrition 54 4.5 Prevention of moderate acute malnutrition 54 4.6 Institutional feeding and school feeding 54 4.7 General food distribution 54 4.8 Nutrition activities delivered through the health sector 55 4.9 Other sector activities with nutrition focus 55 4.10 SWOT analysis of current interventions 55

NUTRITION SITUATION ANALYSIS

ANNEX 2

43

1. Background InformationSomalia is populated by a resilient and highly independent people, whose nomadic tradition plays a major role in determining their collective persona. Clan-based Somali culture has evolved to survive in the harsh and arid environment of the Horn of Africa. Since the collapse of central government in 1991 and resulting civil war, there have been many efforts to restore a central government in Somalia without sustained success. In 1991 the North west zone (NWZ) declared the independent state of Somaliland. This independence has not been recognized by most other countries but Somaliland has remained at relative peace and stability since, with governing administration in the capital Hargesia. The North east Zone (NEZ) declared itself as the autonomous region of Puntland in 1998. Although governed by its administration in its capital Garowe, it pledges to participate in any Somali reconciliation and reconstruction process that should occur. In South Central Somalia political conflict and violence continue to prevail, despite attempts to establish and support a central governing entity.

The combination of conflict, insecurity, mass displacement, recurrent droughts and flooding and extreme poverty, coupled with very low basic social service coverage, has seriously affected food security and livelihoods and greatly increased vulnerability to disease and malnutrition. The MDG health-related indicators are among the worst in the world. Life expectancy is 45 years. One child in every twelve dies before the age of one year while, one child in seven dies before the age of five.

2. Current Nutrition SituationToday, almost all Somalis are affected by the fragile security environment, large-scale population displacements, food insecurity and lack of basic social and health services, with coping mechanisms stretched to the limit as families struggle to absorb these multiple shocks. The result is alarming rates of acute malnutrition and chronic malnutrition throughout the country with some variations by zone and livelihood system.

2.1 Acute malnutrition According to the most recent analysis from FSNAU, the Post Deyr ‘09/10 seasonal assessment, the national median rate of global acute malnutrition (GAM) was 16% based on WHO Growth Standards, compared to 19% for all 34 nutrition surveys conducted prior to the Post Gu 2009 assessment. The median rate of severe acute malnutrition (WHZ < 3 SD) was 4.2% compared to 4.5% Post Gu 2009. These current rates correspond to 1 in 6 (240,0001) children acutely malnourished (WHZ < 2 SD) of which 1 in 22 (63,000) children are suffering severe acute malnutrition with a 9 fold greater risk of early death than their well nourished counterparts. The FSNAU Post Gu assessment 2009 also estimated a further 84,000 pregnant women to be acutely malnourished, a condition which leads to poor intrauterine growth, low birth weight, stunting and developmental delay and predisposes to another generation of malnourished mothers perpetuating the intergenerational cycle of malnutrition.

Within the overall picture there are differences by zone and by livelihood system. Eighty one percent of the acutely malnourished children live in South and Central regions - the areas also affected most by insecurity and restricted humanitarian space. In Somaliland, rates of acute malnutrition are less critical but population density is high, meaning that in a relatively high proportion of total number of acutely malnourished children live there. This has important implications for the geographical coverage of interventions.

1 Caseload figures based on population figures from the UNDP 2005 settlement survey are used as the standard reference for Somalia

44 As highlighted by the Post Gu 2009 assessment and again in the more recent Post Deyr 09/10 assessment, Internally Displaced Populations (IDPs) continue to be the most nutritionally vulnerable, even those in the relative security of the northern regions. The median GAM rate among IDPs is 16.7% which is higher then the national rate, median SAM rate is 5.0% and the median stunting rate of 25% is the highest of all groups. Most IDPs in South Central Somalia are living in overpopulated camps with limited access to water, diversified food and adequate sanitation services. Furthermore, the influx of IDPs from the South to the northern areas has begun to strain already limited social services and create tensions with the local communities.

2.2 Chronic malnutrition The FSNAU Post Deyr 09/10 assessment found very high rates of stunting of 22% in the South Central Somalia compared to 14% in Somaliland and 11% in Puntland. The higher rates in South Central Somalia reflect the chronic volatile situation causing population displacements, lack of administration and public services and loss of livelihoods. This compares to the relative peace and stability in Somaliland.

2.3 Trends in malnutrition- 2001 to 2008Preliminary results from a meta analysis of FSNAU surveillance data 2001 to 2008 reveal that median rates of global acute malnutrition for this period did not vary significantly, remaining at Critical levels (WHO Classification 2000) throughout, with a national median rate of 15.7%. National median rates of stunting for the same period were 23.2%, ie at serious levels according to WHO classification 2000. Rates range from 12.4% in Togdheer region to 37% in Bay region. These results highlight how unacceptably high rates of acute and chronic malnutrition are a persistent problem in Somalia.

Differences in malnutrition among the livelihood zonesFigure 6 shows variation in median malnutrition rates for the period 2001 to 2008 according to type and by livelihood group. Rates of GAM differentiated by livelihood group were not significantly different from the national median rate. However, riverine and agropastoralist groups had the highest median rate of wasting, stunting and underweight suggesting a higher nutritional vulnerability to shocks of flooding drought, displacement and disease outbreak. Pastoralist group had the lowest rates of stunting. This may be due to physical stature masking the actual estimate (Sadler et al 2009).

Differences in malnutrition – Somaliland, Puntland and South Central Somalia Figure 2 highlights how median rates of wasting, stunting and underweight for the period 2001-2008 are all higher in South Central Somalia than Puntland and Somaliland. This reflects the chronic humanitarian situation in the zone where conflict and violence prevail with additional recurrent shocks of drought and flooding causing loss of livelihoods. Somaliland has experienced relative tranquillity and this is reflected in lower rates of malnutrition.

The meta analysis of FSNAU data from 2001 to 2008 also demonstrates how in all but one year (2003), median GAM rates in South Central Somalia exceeded the emergency threshold of 15%. In 2003, the median GAM rate for South Central Somalia was still high at 13.3%.

17.25 15.7

17.9 17.1

12.1

20.6

31.5

19.3

29.7

38.2

14.4

24.6 24.9

19

28 29.5

11

28.9

0

5

10

15

20

25

30

35

40

45

IDP

�Pastoral

Agropastoral

�Riverine Urban Mixed

% p

rev

ale

nc

e

Median Wasting Median stunting Median Underweight

Figure 6: Trends in different types of malnutrition in Somalia by livelihood group

Source: FSNAU 2010

45 The results of the National Micronutrient and Anthropometric Nutrition survey 2009 confirm this pattern of higher prevalence of stunting and wasting in South Central Somalia compared to Somaliland and Puntland (see figure 7). The meta analysis of data for 2010-2008 also reveals variation by region. Gedo region is the worst affected region across the country with a median acute malnutrition rate of 21.5% and a persistently Very Critical nutrition situation. Galgadud (18.4%), Bay (18.0%), Bakool (17.1%) and Hiran (16.7%) also show high median wasting rates over the period 2001-2008.

2.4 Micronutrient malnutritionThroughout Somalia the presence of risk factors for micronutrient malnutrition (poverty, poor access to food, low diet diversity, high morbidity) is high suggesting micronutrient deficiencies are a significant public health problem. The findings of MICS 2006 showed that only 1.2% of households use iodised salt while coverage of Vitamin A supplementation in children 6 to 59 months was 24% but otherwise data on the extent of the problem was limited. In 2009 a national micronutrient and anthropometric nutrition survey was conducted to address the information gap and inform appropriate responses. The national two stage cluster survey was conducted in the three zones to determine the prevalence of vitamin A deficiency, Iron deficiency and anaemia in children 6-59 months and women of reproductive age and iodine deficiency in school aged children and women. Information was also collected regarding infant feeding and care practices and anthropometric status. Field work was completed between March and August 2009, followed by laboratory analysis of samples.

Results of the survey demonstrated the prevalence of both nutritional anaemia and vitamin A deficiency in women and children of all age groups are severe according to WHO classifications and therefore are of significant public health importance.

Anaemia prevalence was 59.3% for children aged 6 to 59 months, 38.5% for school aged children, 46.6% for non pregnant women and 49.1% for pregnant women. In children aged 6 to 59 months, there was no significant difference in prevalence of anaemia between the zones but rural children were found to be 50% more at risk of developing anaemia than their urban counterparts. There was also a significant difference between prevalence of anaemia in children less than two years (73.7%) and those over two (51.9%).

Findings for the prevalence of vitamin A deficiency indicate a severe situation according to the WHO classification of above 20% prevalence, across all zones and each group. Among children 6 to 59 months, the overall prevalence of vitamin A deficiency was 33.3%, with a higher prevalence in South Central Somalia (40.7%) compared to Somaliland (25.6%) and Puntland (24.1%). Similarly, overall prevalence of vitamin A deficiency in school aged children was 31.9% and in women, 54.4%.

1.3

10.7

16.5

4.1

13.9

19.5

5.9

16.5

31.6

4

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23.2

0

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15

20

25

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35

SAM GAM Stunting

pre

va

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ce

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)

NEZ NWZ SCZ Combined

Source: FSNAU 2010

Figure 7: Malnutrition rates by zone, according to National Anthropometric Micronutrient Survey results 2009

Testing for Anaemia, FSNAU

46 Regarding iodine, interestingly, the survey found high urinary iodine concentrations in all groups. The reasons for this are not clear at this stage and will be subject to further investigation. Possible reasons include dehydration of subjects or high iodine content of water but do not include high intakes of iodised salt as overall use of iodised salt was found to be very low at 3.9% (0.4% in the Somaliland, 0.15 in Puntland and 6.7% in South Central Somalia. The prevalence of visible goitre among women was significant in Somaliland at 3.3% compared to 1.4% in South Central Somalia. This indicator was not investigated in Puntland. Goitre can be due to excessive or inadequate intake of iodine.

3. Determinants of Malnutrition in Somalia Malnutrition results from a complex set of factors and not one simple cause. The UNICEF conceptual model of the causes of malnutrition (see figure 8 below) provides a useful framework for the discussion of determinants of malnutrition in Somalia. The volatile political situation and its resulting insecurity, civil unrest or outright war have led to a chronic and continuing humanitarian crisis that is at the root of the high prevalence of malnutrition in Somalia. However, even in years of relative stability and improved food production, the malnutrition rates in some regions of Somalia have remained consistently high, providing evidence for the contribution of underlying causes.

3.1 Food security (Food access and availability)Somalia is chronically food insecure. Overall, around 80% of Somali households rely on natural resource-dependent activities for their livelihood, making them highly vulnerable to environmental factors and shocks. Even in good years, Somalia is only able to produce 40% of its cereal requirements. In the last five years, local production has averaged about 30% of food needs. (ref WFP website). Somalia was a major recipient of international food aid even before the collapse of central government in 1991.

Food security varies wildly by area, season and according to climatic, political and economic factors (openness of cross border markets and internal urban markets). Traditionally, the sedentary farmers of the Juba valley and around Baidoa have suffered the most acute and long lasting nutritional crisis. In comparison the pastoralists have fared best as their mobile, cattle based strategy is flexible and adaptive to the stresses of conflict and insecurity. Pastoralists rely on the consumption and sale of milk and animal products for their livelihoods. Livestock milk availability and consumption has a very significant influence over the nutritional status of the pastoralist population as shown by a case study from West Golis/Guban livelihood zone described in the FSNAU Post Gu 2009 assessment. This shows that once availability of milk declines eg due to loss of livestock resulting from disease outbreak and or drought conditions, rates of acute malnutrition deteriorate to very critical levels but improve again once the livestock situation recovers and availability of milk increases. As discussed in the case study this demonstrates the natural ability to recover from shocks provided that they are not recurrent and cumulative.

According to FEWS Net, underlying causes of food insecurity in the country are the following:•Successive seasons of poor rains and seasonal flood affected crop and livestock production,

which are the two main livelihood sources for the majority of the rural population.•Recurrent conflict and civil insecurity, which have resulted in civilian displacement and

restriction of internal and cross border trade flow.•Chronic macroeconomic shocks, such as the persistent ban of livestock export and lack of

employment opportunities, affected investment in productive sectors like crop and livestock.

Results of the most recently conducted FSNAU led multi-agency post deyr ‘09/10 seasonal assessment indicate some improvement in the overall food security situation in country, especially in rural areas of the south where crop and livestock production has improved following normal deyr rains. However, although the number of people estimated to be in need of emergency

47 humanitarian assistance and livelihood support has dropped to about 3.2 million (42% of the total population), this situation still represents a widespread Humanitarian Crisis affecting 42% of the total population. Conditions in the central regions of Mudug, Hiran and Galgadud are of particular concern. Failure of the deyr rains combined with escalation of conflict and resulting population displacements, on top of six consecutive seasons of drought mean that here 70% of the population are in need of urgent humanitarian assistance, which in turn is more difficult to deliver in the context of heightened insecurity and reduced access. The deyr rains also performed poorly in pastoral regions of the north and north east and has resulted in a deepening crisis in the Hawd, Addun and Sool plateau pastoral livelihood zones, with complete loss of livestock assets, especially sheep and goats.

Figure 8: UNICEF Conceptual model of causes of malnutrition (taken from Lancet series on maternal and child undernutrition 2008

12 | The neglected crisis of undernutrition: DFID’s strategy CHAPTER 3The determinants

Figure 3: Framework of the causes of maternal and child undernutrition and its short term consequences

Short term consequences:

Mortality, morbidity, disability

Household food insecurity

Income poverty: employment, self-

employment, dwelling, assets, remittances,

pensions, transfers etc

Social, economic and political context

Lack of capital: financial, human, physical, social

and natural

Inadequate careUnhealthy household environment and lack

of health service

Long term consequences:

Adult size, intellectual ability, economic productivity, reproductive

performance, metabolic and cardiovascular disease

Inadequate dietary intake Disease

Underlying causes

Basic causes

Immediatecauses

Maternal child undernutrition

Source: Lancet Series on Maternal and Child Undernutrition, 2008.

48 At household level, indicators of food security include number of meals eaten per household per day and diet diversity or number of different food groups consumed a day. Results from the micronutrient study 2009 indicate that food security as measured by number of meals eaten per day is poorer in South Central Somalia where the majority of households (73.7%) consume two meals a day compared to Somaliland where the majority (64.8%) consume three meal a day. In Puntland, 45.2% households reported consuming two meals a day while 41.4% consume three meals a day.

Diversity of the diet at household level also reflects the adequacy of food access and availability. Dietary diversity is generally poor in Somalia and also relates to poor knowledge and food habits. Diets consist mainly of cereal (maize or rice) oil, sugar, seasonably variable access to milk and occasional access to meat. Vegetables and/or fruit are rarely consumed. Patterns differ for pastoralist populations for whom milk makes more significant contribution to the diet. According to the micronutrient study 2009, the percentage of households consuming less than four foods a day was similar across all three zones - between 15 and 20% for South Central Somalia and Somaliland and less than 10% for Puntland; the difference was not significant. The mean number of food groups consumed per day was 5.52. Results from WFP seven day recall assessment in Somaliland (WFP Food Security and Vulnerability Assessment 2008), highlight there is large variation by region and livelihood zone. Overall, 28% of the population consumed less than four food groups in the seven days prior to the survey but in some areas, up to 45% population consumed less than four food groups. 20% of the population were only consuming a staple, oil and sugar. 68% had seasonably variable access to milk and occasionally meat. In Puntland 2007, only 2% of households had a diet that included fruit. Results from the National Micronutrient and Anthropometric Nutrition survey 2009 also show that consumption of micronutrient rich foods including fresh fruits, vitamin A rich vegetables fish, eggs and meat products was generally poor across all three zones.

According to the FSNAU Post Gu 2009 assessment, dietary diversity is particularly poor in Bay and Bakool regions, where surveys found that 49% of Bay agro pastoralists, 55% of Bakool agro pastoralists and 61% of Bakool pastoralist households ate less than 4 food groups in the previous 24 hours. According to the same seasonal assessment, Bay and Bakool regions have the highest rate of chronic malnutrition. The other significant group found to have poor dietary diversity was IDPs in the northwest; 37% of households consumed less than four food groups a day. Poor dietary diversity was identified as a main factor contributing to the Very Critical nutrition situation of this IDP group in the post Gu ‘09 assessment. Generally, urban households are found to have greater household dietary diversity, according to FSNAU data. Preliminary results from the FSNAU meta analysis 2001-2008 highlight the link between diet diversity and nutritional status, finding that children who consumed a less diverse diet (three or fewer food groups) were 1.12 times more likely (p=0.001) to be malnourished than those who consumed more diversified food groups.

Manoocher Deghati IRIN

49 3.2 Social and care environmentThis refers to the ‘wider social and cultural context that shapes caring behaviours within the household and local community’ (Young & Jaspers 2006). Appropriate child care including sound feeding practices, good hygiene, emotional support and appropriate health related behaviours are all essential for good nutrition and health.

The FSNAU KAP survey of 2007 revealed the extent of poor care practices for children and mothers. The study identified the following as significant problems:Poor breast feeding practicesEarly introduction of feeds Birth spacing less than 1.5 yearsInadequate care for women/mothers Poor complementary diets – in particular among riverine and agro pastoralistsPoor hygiene practicesInappropriate home health practices during illnessDelay in seeking appropriate medical care

According to KAPS 2007 findings, throughout Somalia, initiation of breastfeeding is delayed till 2-3 days postpartum, as colostrum, is deemed harmful. However, results of the National Micronutrient and Anthropometric Nutrition survey 2009 shown in figure 9 taken from the survey report, indicate this practice is not as widespread as KAPS 2007 suggests. Overall, around 50% mothers reported initiation of breastfeeding within 3 hours of delivery.

However, while breastfeeding is initiated by most women and practiced well into the 1st month postpartum, breastfeeding is not exclusive. Children are given water with sugar or other liquids such as cow or goat milk. According to a study of breastfeeding and dietary habits of children in rural Somalia (Ibrahim et al 1991), there was a complete absence of exclusive breastfeeding. Median duration of breastfeeding was 19.5 months but all children also received cow’s milk by cup from the first day of life. Sugar, oil and water were also given daily from early infancy. The findings of MICS 2006, indicate that only 9% of infants are exclusively breastfed for 6 months. More recently, the national micronutrient and anthropometric nutrition survey 2009 found rates of exclusive breastfeeding to be 5.3% (95% CI 3.1 – 9.2%), with most mothers giving additional water. With the poor availability of safe water and the poor development of the child immune system, the likelihood of introducing water borne infections is high. Rates of exclusive breastfeeding were lowest in South Central Somalia, only 2.8% (95% CI 0.9 – 8.2%) and highest in Somaliland 12.7% (95% CI 6.7 – 22.7%); the rate in Puntland was 6.3% (95% CI 1.6 – 21.6%). According to the national micronutrient and anthropometric nutrition survey 2009, 60.8% of children aged 12-16 months were still being breastfed. This fell to 26.8% in the 20-23 month age group. Reasons for low levels of breastfeeding in Somalia include lack of knowledge of the importance of the practice, vigorous advertising of infant formulas and the persistence of inaccurate information and myths around breastfeeding. The reasons for apparent better breast feeding practices in Somaliland are worth further investigation and may provide lessons learned to be applied in Puntland and South Central Somalia.

Figure 9: Breast feeding initiation

(Source National Micronutrient and Anthropometric Nutrition Survey 2009)

Furthermore, adequate complementary feeding, defined by frequency and suitability of foods given, among all infants 0 to 11 months was just 11% with little variation according to mother’s education, wealth, or urban-rural residence (MICS 2006), i.e. only one in ten are considered appropriately fed. By 24 months, children are expected to fend for themselves and eat like adults. As highlighted in the previous section, diversity of children’s diets is poor and nutrient density low.

The KAPS study also identified widespread inappropriate home health practices during illness. One indicator of this is the change in frequency with which foods (breastfeeding and/or other foods) are offered during diarrhoea compared to when the child is healthy. According to results of the micronutrient survey, combined data for the three zones showed that 36.2%, 51.5% and 9.6% were offered feeding less that normal, same as normal and more that normal respectively during episodes of diarrhoea. 9.6% and 2.7% of the combined strata were given reduced feeding or withdrawn from feeding completely. Reduced feeding as well as withdrawal during diarrhoea can reduce the chances of full recovery and is an important risk factor for developing severe malnutrition. Practices were found to be particularly poor in Puntland, where no children were given more food, whilst around 70% were given less food than normal and for around 8% food was withdrawn completely during diarrhoea.

Often the care of children is closely linked with cultural and gender issues. In Somali society, women have a progressively stronger role to play in raising children, managing the household and earning income. However, male heads of household continue to make the main decisions over use of time and resources. Generally there is low value placed on women’s health and although they may exercise greater power over health seeking behaviour for their children, they lack decision-making power over their own health. In general, women have far lower levels of education and lower access and utilisation of health services with rural women the most disadvantaged. Furthermore, as figure 10 taken from MICS 2006 below shows, a significant number of pregnancies occur in the 15 to 19 years age group, particularly for rural women. All these factors adversely affect the social and care environment of women and children and therefore their survival and nutritional status.

Maternal mortality ratio (MMR) is estimated as 1044 per 100,000 live births (MICS 2006) which is one of the highest in the region and corresponds to a lifetime risk of 1 maternal death for every 10 women. The high MMR is related to many factors including low age at first birth, high fertility rate, low skilled attendance at birth, poor maternal nutritional status and the presence of female genital mutilation. Limited basic care facilities – referral hospitals, MCH services, almost complete lack of emergency obstetric referral care for complications. According to MICS 2006, around a quarter of pregnant women have one antenatal care consultation. Only 6% of pregnant women visit the antenatal clinic more than 4 times. During delivery, 1 in 3 women are attended by a skilled attendant (doctor nurse, midwife or auxiliary midwife) but less than 10 % delivers in a health facility. Of women who had given birth in the preceding 2 years, 88% had received no postnatal care (MICS 2006). Data on low birth weight is very limited as only 5% of infants in Somalia are weighed at birth. According to MICS 2006, of those weighed at birth, 5% weighed less than 2500g.

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Figure 10: Age-specific fertility rates by urban-rural residence, Somalia 2006

(source: MICS 2006 report)

51 3.3 Access to health services and healthy environment Public health programmes are critical in the prevention and control of disease and therefore in protecting and supporting nutrition. After eighteen years of conflict, the health care system in Somalia remains underdeveloped, poorly resourced, inequitable and unbalanced. The public health care delivery system operates in a fragmented manner, maintained largely by medical supplies provided by UNICEF and other agencies. In the absence of an efficient and adequate public health system, the private sector has flourished but remains unregulated with poor quality of services and poor access to the rural population. Over half of the estimated health workforce is unskilled and unsupervised and staff are paid a below subsistence wage. Most public facilities operate at a level far below their intended capacity and are poorly organized, with very low utilization rates (estimated as on average, one contact every eight years, according to Rossi and Davies 2008).

According to KAP study 2007, most health seeking responses are based on the traditional knowledge, beliefs and the perceived causes of the specific illnesses. Traditional healing and the use of herbal medicine play a major role in the management of illnesses for most communities. Across all livelihood zones, the first step in health seeking response for most caregivers is prayer or reading the Koran, after which most people buy drugs. Visiting a health facility only comes after all else has failed. There is a general lack of confidence towards public institutions.

Not surprisingly, overall coverage of essential health services is low, especially for rural and nomadic populations. According to MICS 2006, immunization coverage (1 year olds fully immunized) was only 5%, while 12% of children aged 12 to 23 months had received all three doses of DPT, for measles 29%. Of mothers who gave birth in the previous two years before the MICS 2006, only 9 percent received a Vitamin A supplement within eight weeks of the birth. Within the six months prior to the MICS, 24 percent of children aged 6-59 months had received a high dose Vitamin A supplement. More recent data from the national micronutrient and anthropometric nutrition survey 2009 results are summarised in figure 11 and suggest improved coverage of both immunisation and vitamin A. Overall coverage of vitamin A was 44.6% for children under five years of age. Coverage for Somaliland and South Central Somalia was significantly higher but this was related to recent implementation of Child Health Days in the two zones prior to the survey being conducted.

A healthy environment in terms of adequate supplies of clean water, sufficient sanitation, appropriate shelter and clothing are crucial in terms of reducing exposure to disease. Throughout Somalia, the water and sanitation situation is extremely poor. MICS 2006 found that only 29% of the population had access to an improved source of drinking water (58% in urban areas, 14% in rural areas, 4% in nomadic groups). 81% of the rural population practices open defecation. More recently, the national micronutrient and anthropometric nutrition survey 2009 reported the use of improved water source in Somalia overall to be 32%. This suggests some improvement in access to safe water may have taken place over the four years between surveys.

Figure 11: Immunisation coverage among children under five years

Source Micronutrient Survey 2009

Only just over half of households (55%) report that soap in the household was used for washing hands in one or more of the given situations (MICS 2006). The lack of clean water, poor hygiene and environmental sanitation are major causes of diseases in particular diarrhoeal diseases and cholera. Diarrhoeal diseases are the cause of 19% of deaths of children under five. According to MICS 2006, only 7% of children with diarrhoea receive appropriate treatment (ORS and continued feeding). Preliminary results from the FSNAU meta-analysis 2001-2008 indicate that diarrhoea is a significant predictor of acute malnutrition. The paradox is that the water and sanitation situation are major underlying cause of morbidity and malnutrition in Somalia, yet interventions have been relatively poorly funded.

The relationship between malnutrition and morbidity is well established. Disease outbreaks have shown to have a significant effect on malnutrition rates in Somalia. In Lower and Middle Juba regions, since March 2009 an outbreak of acute watery diarrhoea across all livelihoods coincided with a significant deterioration in the nutrition situation to Very Critical despite improvements seen in food security indicators in the region. In Shabelle and Juba, high rates of malnutrition were attributed to high incidence of acute watery diarrhoea and acute respiratory tract infections (FSNAU Post Gu 2009 assessment).

3.4 EducationThe UNICEF conceptual model highlights inadequate education as one of the basic causes of malnutrition. According to UNICEF, only 24% of women are literate, while 20% of girls attend school. Overall 23% of children (25% of boys and 21% of girls) of primary school age attend primary school, (44% urban, 12% rural). For every 10 boys attending primary school, there are 8 girls, while for secondary school, for every 10 boys attending, only 5 girls. A large number of secondary school age children attend primary school due to lack of schooling opportunities that followed the overthrow of Siad Biarre in 1991 and the social chaos.

While each of these groups of underlying causes has been discussed independently of each other, there is a clear inter-connectedness between them. Underlying causes are overlapping and have a synergistic effect so that the combined effects of a failure of all three causes are much greater than the sum of their parts. This is the foundation of the need for an integrated, multi sectoral response. As discussed, different causes differ in their significance for the different regions and livelihoods. For example in urban populations, dietary diversity is much better than for the rural populations, and sub optimal care practices such as use of breast milk substitutes may be more significant in the explanation of malnutrition.

4. Current Nutrition Interventions In response to persistently high rates of acute malnutrition, current nutrition interventions have been focused on saving lives through the management of acute nutrition. 4.1 Nutrition Cluster Due to weak governance structures in parts of Somalia, nutrition response programming is mainly undertaken by UN, international and national agencies. The Nutrition Working Group (NWG) was initiated in 1995 to coordinate nutrition related issues. In 2006, as part of the UN Humanitarian Reform, the cluster approach was introduced. From the start this was integrated into the existing NWG. Thus the Nutrition Cluster and NWG exist as a single coordination structure, referred to as the Nutrition Cluster, for nutrition activities in Somalia. The primary purpose of the Nutrition Cluster is “to support and strengthen a coordinated approach in nutrition strategic planning, situation analysis and response both in emergencies and non-emergency situations.” (Nutrition Cluster TORs Dec 2009). There are currently 79 members of the Nutrition Cluster including local and international NGOS and UN agencies working in the field of nutrition in Somalia.

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53 4.2 Food Security and Nutrition SurveillanceThe Food Security and Nutrition Analysis Unit (FSNAU) is managed by FAO and funded by USAID/OFDA, the EC, SIDA, UNICEF and UNHCR. It has developed a very sophisticated system of regular and exhaustive food security and nutrition assessments. Information is collected through different surveillance systems including nutrition surveys, rapid Mid Upper Arm Circumference (MUAC) assessments, passive health facility-based screening and at some times and places, sentinel site surveillance. Data is analysed in the context of morbidity and food security indicators. Bi monthly nutrition updates are produced and bi annual assessments of the food security and nutrition situation are published. The food security and nutrition surveillance data is an important tool providing regular situational analysis to inform and guide appropriate responses to expected caseloads of acutely malnourished and emerging needs.

Additional food security information is provided through the Famine Early Warning Systems Network (FEWS NET). This is a USAID-funded activity that collaborates with international, regional and national partners to provide timely and rigorous early warning and vulnerability information on emerging and evolving food security issues. FEWSNET produces monthly food security updates, regular food security outlooks and alerts, as well as briefings and support to contingency and response planning efforts. More in-depth studies in areas such as livelihoods and markets provide additional information to support analysis as well as program and policy development.

WFP undertakes regular monitoring of market prices and has conducted baseline livelihood studies. Food security and vulnerability assessments have been conducted and published for Puntland in April 2007 and Somaliland in August 2008. Smaller assessments have completed in Mogadishu, Bossaso, El Wak in the South. A food security and vulnerability assessment is planned for Central region in 2010.

4.3 Management of severe acute malnutritionOutpatient therapeutic feeding programmes (OTPs) for the treatment of severe acute malnutrition are being implemented across Somalia by international NGOs and UNICEF in partnership with local NGOs, according to the “Operational Guidelines for the Treatment of Acute Malnutrition in Somalia” which were developed by the nutrition cluster in 2005, taking into account the challenging environment, reduced supervision and limited monitoring. Complicated cases are referred to stabilisation centres (SCs) for the initial period of treatment, although distance and location of centres in opposing clan territories are often barriers to access. WFP provides a caregiver and discharge rations in selected centres across Somalia. In 2009, UNICEF aimed to reach 60% of children under five with severe acute malnutrition through technical support and training of NGO partners and distribution of feeding supplies. At the time of writing there are 250 outpatient units for the ambulatory treatment of severe acute malnutrition in Somalia and around 20 in patient stabilisation centres, all but four integrated into existing health structures. This scale up of services for the management of acute malnutrition is impressive but gaps remain in the geographical coverage of OTPs and SCs due to the insecure environment, fragmented health system and availability of capable local partners. Map 1 on page 7 shows a map of the current nutrition situation and interventions as of November 2010.

Measuring MUAC, IDP camp, Jowhar, UNICEF Somalia, Nick Ysenburg

54 4.4 Management of moderate acute malnutritionTargeted supplementary feeding programmes (SFPs) for the treatment of moderately malnourished under-fives and pregnant and lactating women are being implemented by WFP through around 40 local and international NGOs. The current caseload is around 70,000 beneficiaries, of whom approximately 80% are under-fives and 20% pregnant and lactating women. 50,000 beneficiaries are being treated with corn soya blend (CSB), fortified vegetable oil, and sugar. In a pilot intervention, 20,000 are to receive ready-to-use supplementary food (supplementary plumpy) in Bakool, Bay, and Benadir regions of South Central Somalia, and in Puntland and Somaliland. In addition, WFP is providing a ‘protection’ ration for families of moderately malnourished under -fives. This currently provides around 60% of the energy needs of the family.

4.5 Prevention of moderate acute malnutrition – food based interventionsIn selected sites in Puntland and Somaliland, WFP is providing fortified supplementary food to all children under-two and pregnant and lactating women through UNICEF supported MCH clinics. Currently 35 clinics are supported.

As a new initiative, during 2009 UNICEF launched a pilot intervention for the prevention of malnutrition targeting 100,000 children aged 6-36 months blanket distribution of ready-to-use food (Plumpy Doz) every two months in areas showing the highest malnutrition rates, with a particular focus on the Central and South Somalia, in Middle and Lower Shabelle and IDP camps in the north and poor urban areas.

From May to August 2009, WFP launched and completed an emergency blanket supplementary feeding covering 135,000 children aged 6-59 months in Galgadud and Mudug regions of Central Somalia as well as South Nugal in Puntland. This intervention was designed to prevent and treat moderate malnutrition in areas where very critical rates of malnutrition were recorded (GAM>20%) with very limited access to nutrition services.

4.6 Institutional Feeding & School FeedingWFP is providing nutritional support to other vulnerable groups including HIV positive and TB cases, orphans, the mentally handicapped, and hospitalized patients either as a take home ration or as daily meals for in patients. This intervention currently supports 60,000 people including the family protection ration.

Around 90,000 school children provided with meals at school from fortified foods. Girls receive a take home ration of fortified oil to encourage attendance.

4.7 General food distributionWFP is providing food assistance to the rural population affected by the humanitarian crisis, the urban poor and IDPs with general food ration consisting of cereals, CSB, sugar, fortified oil and iodised salt when available. In 2009 WFP reached 3.3 million people a month on the basis of FSNAU seasonal assessments.

School feeding, WFP Khalif

55 4.8 Nutrition activities delivered through the health sectorNutrition interventions are delivered through the 3 levels of the health system – health posts, MCH Clinics and hospitals. Coverage and quality is currently limited due to overall weaknesses of the public health system.

A key intervention of the UNICEF/WHO Accelerated Young Child Survival initiative is the bi annual Child Health Days. These population based campaign days aim to provide at least 80 per cent of under-fives and over 60 per cent of women of child bearing age nationwide with high-impact child survival interventions: immunization against measles, polio, vitamin A supplementation, deworming, provision of oral rehydration salts, water treatment tablets, hygiene education, nutritional screening, and tetanus toxoid vaccination for women. These campaign days are especially important in the context of the majority nomadic and rural population who have limited access to regular health services.

4.9 Other sector activities with nutrition focus- FAO Trials of Improved Practices. This project aims to identify and implement the most acceptable practices in the region for improving infant and child feeding practices. The method involves discussion with the mothers and caregivers in moving towards recommended IYCF over three household visits. The aim is to move from ideal recommendations to practical realistic recommendations. The project has been piloted in Hiran and Gedo regions which were identified by KAPs 2007 as being particularly vulnerable in IYCF.

- EU and FAO Integrated Support to Rural Livelihoods. The aim of this project is to mitigate the effects of soaring food prices in 2009 for 78,100 households in South Central Somalia. It aims to enhance agricultural production through cash for work programmes, distribution of packaged seed kits, tools and fertilizers. Resulting improvements to livelihood and food security should have a positive impact on nutritional status.

4.10 Strengths, weaknesses, opportunities and threats of current interventionsTable 1 summarises a SWOT analysis of the current nutrition interventions in Somalia. This analysis highlights the strengths of nutrition and food security surveillance and the current interventions for the management of acute malnutrition; weakness in areas of interventions to address underlying causes of malnutrition; opportunities for integration of complementary activities into existing nutrition programmes and the significant threats to quality programming by insecurity and poor access, weak health systems and low human resource capacity. In such a challenging operating environment, the use of existing programmes and structures as a delivery mechanism for integrated activities is crucial.

Table 2 summarises key existing initiatives and the opportunities they offer as delivery mechanisms for strengthening nutrition interventions.

56

Op

po

rtu

nit

ies

1.

Inte

grat

ion

of n

utrit

ion

activ

ities

into

exi

stin

g pr

ogra

mm

es –

(see

tabl

e 2)

2.

Inte

grat

ion

of I

YC

F, h

ygie

ne p

rom

otio

n, d

eliv

ery

of b

asic

hea

lth s

ervi

ces

into

exi

stin

g nu

tritio

n pr

ogra

mm

es (O

TP/S

FP s

ites)

3.

Pro

ven

effe

ctiv

e in

terv

entio

ns th

at a

re c

ost e

ffect

ive

are

avai

labl

e (L

ance

t se

ries,

Cop

enha

gen

cons

ensu

s) o

f w

hich

are

fea

sibl

e to

Som

alia

in t

he

next

thre

e ye

ars

4.

Exi

stin

g in

tern

atio

nal g

uide

lines

and

reso

urce

s th

at c

an b

e ad

apte

d to

the

Som

ali c

onte

xt

5.

Pilo

t of

new

ini

tiativ

es b

y sp

ecifi

c ag

enci

es –

FA

O T

IPS

, C

omm

unity

C

onve

rsat

ions

by

Con

cern

Wor

ldw

ide

6.

In g

ood

year

60%

cer

eals

are

im

porte

d, c

reat

ing

oppo

rtuni

ty f

or c

erea

l fo

rtific

atio

n at

sou

rce

7.

Dev

elop

men

t of i

mpr

oved

CS

B b

y W

FP H

Q

8.

Dev

elop

men

t of

oth

er p

rodu

cts

for

mic

ronu

trien

t su

pple

men

tatio

n eg

sp

rinkl

es, n

utrib

utte

r whi

ch fo

cus

on fo

rtific

atio

n at

poi

nt o

f use

9.

Mic

ronu

trien

t su

pple

men

tatio

n ha

s hi

gh c

ost

bene

fit r

atio

. C

open

hage

n co

nsen

sus

10.

Exi

stin

g pr

e-se

rvic

e tra

inin

g in

stitu

tions

– o

ppor

tuni

ties

for

deve

lopi

ng

nutri

tion

curr

icul

um

– do

ctor

s,

nurs

es,

nutri

tion

cour

ses.

Li

nks

to

inte

rnat

iona

l ins

titut

ions

11.

Inte

rnet

acc

ess

in S

omal

ia f

or li

nks

to w

ell r

ecog

nise

d di

stan

ce le

arni

ng

cour

ses

for c

apac

ity d

evel

opm

ent

Th

reat

s1.

P

rolo

nged

abs

ence

of u

nifie

d ce

ntra

l gov

ernm

ent l

imiti

ng o

ptio

ns fo

r nat

iona

l pol

icy

fram

ewor

k an

d gu

idel

ines

2.

Inse

curit

y an

d co

nflic

t re

duci

ng a

cces

s to

sup

ervi

se a

nd e

xpan

d pr

ogra

mm

es,

train

sta

ff,

deve

lop

outre

ach

activ

ities

3.

Loot

ing

of s

uppl

ies

disr

uptin

g pi

pelin

e an

d di

strib

utio

n

4.

Glo

bal e

cono

mic

situ

atio

n an

d po

litic

al is

sues

affe

ctin

g fu

ndin

g of

pro

gram

mes

5.

Sho

rt te

rm fu

ndin

g fo

cuse

d on

em

erge

ncy

inte

rven

tions

rat

her

than

med

ium

to lo

nger

term

in

itiat

ives

6.

R

ecur

rent

dro

ught

s an

d flo

ods,

7.

A

ctiv

e pr

omot

ion

and

adve

rtisi

ng o

f br

east

milk

sub

stitu

tes.

Eco

nom

ic in

tere

sts

of t

rade

rs/

impo

rters

8.

Trad

ition

al,

gene

ralis

ed p

oor

feed

ing,

hyg

iene

, sa

nita

tion

and

mat

erna

l an

d ch

ildre

n ca

re

prac

tices

9.

Dis

pers

ed n

atur

e of

mal

nour

ishe

d po

pula

tion

over

wid

e ge

ogra

phic

al a

rea

10.

Diffi

culti

es o

f pro

vidi

ng h

ealth

and

nut

ritio

n se

rvic

es to

a s

ubst

antia

l nom

adic

pop

ulat

ion

and

in

arid

low

pop

ulat

ion

dens

ity a

reas

11.

Wat

er a

nd s

anita

tion

situ

atio

n12

. W

omen

’s p

ositi

on in

Som

ali s

ocie

ty e

spec

ially

in r

ural

are

as -

low

er le

vels

of e

duca

tion

and

low

er a

cces

s an

d ut

ilisa

tion

of h

ealth

ser

vice

s 13

. H

uman

reso

urce

s fo

r nut

ritio

n –

educ

atio

nal l

evel

gen

eral

ly v

ery

poor

, nut

ritio

n tra

inin

g in

pre

se

rvic

e in

stitu

tions

lim

ited,

Wea

knes

ses

1.

Geo

grap

hic

gaps

in c

over

age

of m

anag

emen

t of a

cute

mal

nutri

tion

2.

Li

mite

d st

abili

satio

n ce

ntre

s fo

r co

mpl

icat

ed s

ever

e ac

ute

mal

nutri

tion

– di

stan

ce,

trans

port,

cro

ssin

g cl

an a

reas

3.

Low

rep

ortin

g of

fee

ding

pro

gram

me

perfo

rman

ce in

dica

tors

– on

ly 6

0% f

rom

UN

ICE

F im

plem

entin

g pa

rtner

s4.

M

appi

ng o

f cur

rent

nut

ritio

n in

terv

entio

ns is

unr

ealis

tic -

age

ncie

s ha

ve s

topp

ed b

ut n

ot

refle

cted

on

inte

rven

tions

map

5.

La

ck o

f int

egra

tion

of e

ssen

tial c

ompl

emen

tary

act

iviti

es in

to e

xist

ing

nutri

tion

prog

ram

mes

eg

dew

orm

ing,

IY

CF,

nut

ritio

n an

d hy

gien

e ed

ucat

ion

to g

ive

com

plet

e pa

ckag

e of

se

rvic

es,

6.

Poo

r qu

ality

& c

over

age

of n

utrit

ion

inte

rven

tions

del

iver

ed t

hrou

gh h

ealth

fac

ilitie

s –

nutri

tion

coun

selli

ng, m

icro

nutri

ent s

uppl

emen

tatio

n, d

ewor

min

g7.

Li

mite

d IY

CF

inte

rven

tions

8.

Mic

ronu

trien

t int

erve

ntio

ns li

mite

d to

CH

Ds,

forti

fied

ratio

ns &

SFP

s 9.

E

ffica

cy o

f ble

nded

food

(C

SB

) fo

r m

anag

emen

t of m

oder

ate

mal

nutri

tion

is lo

w d

ue to

hi

gh p

hyta

te c

onte

nt a

nd p

ract

ical

diffi

culti

es to

pre

mix

ble

nded

food

with

oil

and

suga

r. W

eak

supe

rvis

ion

also

redu

ces

succ

ess

10.

Doc

umen

tatio

n of

exp

erie

nces

of w

hat w

orks

in S

omal

i con

text

11.

Con

stra

ints

on

mon

itorin

g an

d ev

alua

tion

due

to a

cces

sibi

lity

issu

es

Str

eng

ths

1.

Out

patie

nt m

anag

emen

t of

sev

ere

acut

e m

alnu

tritio

n us

ing

adap

ted

inte

rnat

iona

l pro

toco

ls to

the

situ

atio

n in

Som

alia

– fl

exib

le a

ppro

ach

2.

The

qual

ity o

f foo

d se

curit

y an

d nu

tritio

n su

rvei

llanc

e in

form

ing

appr

opria

te

resp

onse

s3.

N

utrit

ion

clus

ter c

o-or

dina

tion

– m

embe

r par

ticip

atio

n co

oper

atio

n4.

Tr

ials

of

new

app

roac

hes

to m

anag

emen

t of

mod

erat

e m

alnu

tritio

n –

Sup

plem

enta

ry P

lum

py a

nd p

reve

ntio

n of

mal

nutri

tion

- Plu

mpy

Doz

5.

D

edic

ated

par

tner

s w

ho h

ave

scal

ed u

p se

lect

ive

feed

ing

inte

rven

tions

de

spite

ong

oing

inse

curit

y

Tabl

e 1:

SW

OT

Ana

lysi

s of

cur

rent

nut

ritio

n in

terv

entio

ns in

Som

alia

57

Prog

ram

me

& o

verr

idin

g ob

ject

ives

Key

nut

ritio

n re

late

d pr

ogra

mm

e ob

ject

ives

Key

pro

gram

me

activ

ities

Opp

ortu

nitie

s fo

r int

egra

tion

of n

utrit

ion

activ

ities

Uni

ted

Nat

ions

Tra

nsiti

on P

lan

for

Som

alia

200

8-09

Thre

e co

re ‘p

illars

’ or o

vera

ll go

als:

i)

Dee

peni

ng p

eace

, im

prov

ing

secu

rity

and

esta

blis

hing

goo

d go

vern

ance

; (ii

) Inv

estin

g in

peo

ple

thro

ugh

impr

oved

so

cial

ser

vice

s; a

nd

(iii)

Cre

atin

g an

en

ablin

g en

viro

nmen

t fo

r pr

ivat

e se

ctor

-led

grow

th t

o ex

pand

em

ploy

men

t and

redu

ce p

over

ty

Mor

e w

omen

of r

epro

duct

ive

age

and

child

ren

bene

fit fr

om im

prov

ed a

cces

s to

qua

lity

heal

th

serv

ices

incl

udin

g ch

ild s

urvi

val s

ervi

ces.

Targ

eted

ben

efici

arie

s ha

ve im

prov

ed n

utrit

iona

l st

atus

Hea

lth w

orke

rs, e

spec

ially

wom

en, i

nse

lect

ed d

istri

cts

are

able

to p

rovi

de b

ette

r cur

ativ

e an

d pr

even

tive

serv

ices

on

the

basi

s of

a p

acka

ge o

f es

sent

ial s

ervi

ces.

Hea

lth a

nd n

utrit

ion

com

mun

icat

ion

stra

tegy

ad

apte

d, e

xpan

ded

and

impl

emen

ted

Com

mun

ities

and

targ

eted

fam

ilies

have

impr

oved

ca

paci

ty in

pro

cess

ing,

pre

para

tion

and

stor

age

of

food

Com

mun

ities

and

targ

eted

fam

ilies

have

impr

oved

aw

aren

ess

of n

utrit

iona

l val

ues

of lo

cally

ava

ilabl

e/in

trodu

ced

food

UN

TP c

apac

ity d

evel

opm

ent s

trate

gy

Hea

lth a

nd n

utrit

ion

com

mun

icat

ion

stra

tegy

UN

ICEF

/WH

O A

ccel

erat

ed Y

oung

Chi

ld

Surv

ival

Initi

ativ

e (A

YCS)

Key

obje

ctiv

e is

to

focu

s on

exp

andi

ng

acce

ss fo

r you

ng c

hild

ren

and

mot

hers

to

a ke

y se

t of c

ritic

al lif

e sa

ving

inte

rven

tions

im

med

iate

ly a

nd in

the

long

er te

rm.

(1) C

ontin

ue w

ith lif

e sa

ving

em

erge

ncy

inte

rven

tions

(2

) Ex

pand

acc

ess

to l

ife s

avin

g in

terv

entio

ns f

or

all

child

ren

thro

ugh

inst

itutio

naliz

ing

high

im

pact

po

pula

tion

orie

nted

ser

vice

s in

clud

ing

cam

paig

n an

d ou

treac

h m

odes

(3

) Ex

pand

ac

cess

an

d ut

ilizat

ion

of

the

basi

c he

alth

car

e sy

stem

thr

ough

incr

ease

d co

vera

ge o

f co

mm

unity

bas

ed s

ervi

ces

and

refe

rral

(4) U

se m

ass

and

inte

r-per

sona

l com

mun

icat

ions

to

prom

ote

posi

tive

beha

viou

ral c

hang

e an

d im

prov

ed

heal

th s

eeki

ng b

ehav

iour

s.

Chi

ld h

ealth

day

aim

to p

rovi

de 9

0 pe

r cen

t of u

nder

-fiv

es a

nd o

ver 6

0 pe

r cen

t of w

omen

of c

hild

bea

ring

age

natio

nwid

e w

ith

high

-impa

ct

child

su

rviv

al

inte

rven

tions

: im

mun

izat

ion

agai

nst

mea

sles

, po

lio,

diph

ther

ia,

pertu

sis

and

teta

nus

vi

tam

in

A su

pple

men

tatio

n, d

ewor

min

g, p

rovi

sion

of

oral

re

hydr

atio

n sa

lts,

wat

er t

reat

men

t ta

blet

s, h

ygie

ne

educ

atio

n, n

utrit

iona

l scr

eeni

ng, a

nd te

tanu

s to

xoid

va

ccin

atio

n fo

r wom

en;

Opp

ortu

nity

fo

r nu

tritio

n cl

uste

r to

pr

ovid

e in

puts

to

impr

ove

qual

ity a

nd c

over

age

of

nutri

tion

inte

rven

tions

pro

vide

d th

roug

h C

HD

ie

vita

min

A, d

ewor

min

g an

d nu

tritio

n sc

reen

ing

Tabl

e 2:

Exi

stin

g pr

ogra

mm

es p

rese

ntin

g op

port

uniti

es fo

r int

egra

ting

nutr

ition

act

iviti

es in

Som

alia

58 W

HO

/UN

ICEF

G

AVI

Hea

lth

Syst

em

Stre

ngth

enin

g St

reng

then

ing

of m

ater

nal

child

hea

lth c

entre

s &

heal

th p

osts

(40

MC

H +

80

heal

th p

osts

thro

ugho

ut

3 zo

nes)

Rec

ruitm

ent t

rain

ing

and

depl

oym

ent o

f 240

fem

ale

com

mun

ity h

ealth

wor

kers

(FC

HW

s)

Beha

viou

r Com

mun

icat

ion

Cha

nge

(BC

C) s

trate

gy

Ope

ratio

nal r

esea

rch

Thro

ugh

colla

bora

tion

with

he

alth

se

ctor

, nu

tritio

n co

mpo

nent

of

MC

H s

ervi

ces

can

be

stre

ngth

ened

– d

evel

opm

ent

of s

tand

ardi

sed

prot

ocol

s, c

ompr

ehen

sive

trai

ning

( pr

e-se

rvic

e an

d in

ser

vice

) su

perv

isio

n an

d m

onito

ring

in f

ollo

win

g ar

eas:

ass

essm

ent

of n

utrit

iona

l st

atus

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60

In this section, internationally recognised, proven effective interventions are linked with the priorities identified for Somalia and what is feasible in the context.

Outcome 1 Improved access to and utilisation of quality services for the management of malnutrition in women and children

The Lancet series on Maternal and Child undernutrition (2008) highlights that recent studies demonstrate new commodities such as ready to use therapeutic food (RUTF) can be used effectively to manage severe acute malnutrition in community settings. The Community based management of acute malnutrition (CMAM) approach increases the number of children who can be treated, reduces exposure to disease and reduces drop-out rates compared to standard management of acute malnutrition approach using therapeutic milks in a centre based setting (Collins et al 2006).

The development of RUTF and the CMAM approach has opened the door to significant expansion of services for the management of severe acute malnutrition in Somalia where the weak health infrastructure and high insecurity have been major challenges to centre based management. Since 2006, 250 OTPs supported by UNICEF have opened. Some coverage gaps remain particularly with respect to access to stabilisation centres or adequate facilities for referral of complicated cases. This is especially so in South Central Somalia where the majority of SAM cases live but humanitarian space is most limited. Quality of services is also an issue. Thus, the enhancement and expansion of quality interventions for the management of acute malnutrition in accordance with newly developed guidelines remains a priority. Whilst poor coverage of referral centres continues to be a major constraint to providing quality services, the promotion of community mobilisation as a key activity of all OTPs is an important approach to improving coverage and early diagnosis to reduce the presentation of complicated cases in need of referral. As it is such a key activity in this context, community mobilisation requires dedicated staff and resources.

The results of the micronutrient and anthropometric survey 2009 underscore the importance of scaling up services for the treatment of micronutrient deficiencies. Treatment services are currently limited by weakness in the health system and by poor access to and utilisation of health facilities. However, while not a remit of this strategy, health system strengthening is an overarching goal. The development of simple Somali specific standardised protocols in conjunction with pre-service and in service training modules on diagnosis and treatment of MND for all health staff, and commitment to timely provision of supplies, will contribute to improving treatment services.

JUSTIFICATION OF OUTCOMES AND KEY APPROACHES ADOPTED IN THIS STRATEGY

ANNEX 3

Child eating Plumpynut Save the Children, Somaliland

61 Management of malnutrition also involves its prevention. As highlighted in the section on outcome 2, behaviour change communication strategies to improve complementary feeding practices have been proven effective in improving growth outcomes in young children. However, as the Lancet series on undernutrition concluded, such strategies alone were of most benefit in populations that had sufficient means to procure appropriate food. In food insecure populations, nutrition education had a greater impact when food or food supplements were provided. Furthermore, the recent review of complementary feeding (Dewey and Adu-Afarwuah 2008) found that interventions in which micronutrient supplementation alone was provided generally had little or no effect on growth.

This strategy includes key outputs for addressing longer term goals of improving diet diversity and increasing consumption of local nutrient dense foods. However, in the meantime the evidence cited above underscores the importance of providing food based interventions to meet energy and protein, as well as micronutrient, requirements for the prevention of undernutrition in high risk areas of food insecurity in Somalia. In these areas where locally available foods alone will not satisfy nutritional requirements, additional food products can fill a critical gap in nutrients as a complement to continued breastfeeding and the local diet, not as a replacement. Thus food based interventions will be accompanied by counselling on continued breastfeeding, responsive feeding and good hygiene practices.

The review by Dewey and Abu-Afarwuah (2008) also found that in several studies the impact of providing a complementary food in combination with nutrition education was evident only in the younger children. This reiterates the ‘critical window of opportunity’ and the importance of targeting food based interventions to prevent undernutrition in the 6 to 24 months age group.

In Somalia the options for products for food based interventions are corn soy blend (CSB) or the new lipid-based nutrient supplements (LNS). LNS are a range of products fortified with multiple micronutrients and in which lipid is the primary source of energy. There are pros and cons to both types of products. Blended food has long been used in Somalia. Its acceptability is proven, it is cheap and there are limited pipeline issues. On the negative side, the efficacy of blended food has more recently been questioned with varied results achieved. The energy density of blended food is low compared to the stomach capacity of a small child. The high phytate content of the current CSB inhibits micronutrient absorption while there is a lack of animal protein. Furthermore there are two factors of the Somali context which further reduce the efficacy of CSB. Firstly, it is rarely possible to premix blended food with oil and sugar therefore energy density is compromised. Secondly, limited supervision is possible and weak supervision has been demonstrated to reduce success (Navarro-Colorado et al 2008)). In addition, a recent review article found evidence of the efficacy of fortified blended foods for improving nutritional outcomes to be currently limited and weak (Perez-Exposito and Klein 2009). Two new products under development, CSB+ (pregnant & lactating women, children 2-5 years) and CSB++ (children under two), may improve the effectiveness of blended food in the future.

Child eating Plumpydoz, IDP camp Jowhar, UNICEF Somalia

62 The advantages of LNS pertinent to the Somali context include: LNS are high quality fortified foods that can be used at home without the need for water or premixing or cooking; they are stable and resistant to spoilage, the micronutrients do not interact; they provide additional energy and increase energy density of complementary foods; they have been proven to improve linear growth of young children and proven more effective than CSB in supplementary feeding of moderately malnourished children (Nackers et al 2010). LNS in the form of the product ‘Plumpy Doz’ has been used in Somalia under operational research conditions. However with high prevalence of acute malnutrition and limited contacts with beneficiaries, evaluating and documenting impacts have proved difficult. Thus cost compared to nutritional benefit is as yet undetermined in the context.

Outcome 2 Sustained availability of timely and quality nutrition information and operational research into effective responses to the causes of undernutrition

Quality and timely nutrition information is essential to defining appropriate & feasible nutrition response options. Whilst more is known about the underlying causes of undernutrition throughout Somalia from KAPs 2007, the national micronutrient and Anthropometric Survey 2009, FSNAU data, less is known about the types of interventions that can impact on the problem, particularly in the Somali context. Operational research is therefore key to providing the evidence base on which appropriate programmes can be planned.

Outcome 3 Increased appropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition

KAPS 2007 and Micronutrient survey 2009 reveal the extent of inappropriate knowledge, attitudes and practices regarding infant, young child and maternal nutrition throughout Somalia. Rates of exclusive breastfeeding are extremely low at around 5% (National Micronutrient and Anthropometric Nutrition survey 2009). According to KAPS 2007, the practice of discarding colostrum is widespread. Infant formulas are vigorously promoted in a context of widespread poor water, sanitation and hygiene conditions. In contrast, the Lancet series on Maternal and Child Undernutrition 2008 identifies that exclusive breastfeeding in the first six months of life is particularly beneficial while infants who are not breastfed in the first month of life may be as much as 25 times more likely to die than infants who are exclusively breastfed. Continued breastfeeding is also very critical to improve feeding in children 6-23 months of age, as breast milk is an important source of energy and nutrients in the child’s diet.

The Lancet series on Maternal and Child Undernutrition 2008 shows that both individual and group counselling have been demonstrated to extend the duration of exclusive breastfeeding. In Somalia individual counselling of mothers on appropriate breastfeeding practices and improving family and community understanding and support for early initiation and exclusive breastfeeding to six months are important. However, the other key priority is to address the vigorous advertising of breast milk substitutes by engaging with importers and traders. While the absence of a legislative framework is appreciated, it is important that a longer term consultative process on adoption of the International code for marketing of Breast milk substitutes is initiated.

Poor infant and young child feeding practices, including bottle-feeding in deplorable conditions is a predisposing factor to diarrhoea and malnutrition, FSNAU, Dec, 2009

63 As highlighted in the situation analysis young child feeding practices in Somalia tend to be inadequate, with only one in ten children being appropriately fed. Energy density of complementary feeds is low and diet diversity poor. A recent review of 42 efficacy trials and effectiveness studies on complementary feeding interventions concluded that carefully designed programmes that include pre-tested educational messages provided through multiple channels had an effect in improving complementary feeding. A greater impact was seen when animal-source foods were specifically promoted in the messages or when food supplements were provided as well. Educational strategies should focus on imparting the knowledge and develop skills to maximise use of locally-available, high-quality foods, as well as food safety, cultural beliefs and intra-family food distribution. As recommended in the review, this strategy aims to deliver nutrition counselling through multiple channels, individual, community and mass media integrated into the programmes that reach mothers and children ie nutrition programmes, schools, community based initiatives and MCH and outreach services. The integration of support for IYCF into the CMAM approach, piloted in Sierra Leone and Zimbabwe by UNICEF & Save the Children UK may be a useful model to adapt to Somalia.

Outcome 4 Improved availability and coverage of micronutrients and de-worming interventions to the population

Micronutrient malnutrition has wide-ranging effects on health, learning ability and productivity and has high social and public costs leading to reduced work capacity due to high rates of illness and disability. As highlighted in the situational analysis, prevalence of both nutritional anaemia and vitamin A deficiency in women and children in all three zones of Somalia are above WHO thresholds for the classification of a severe situation. There are different approaches to preventing micronutrient malnutrition. The best way is to ensure the consumption of a balanced diet but this requires universal access to adequate food and appropriate dietary habits, neither of which reflect the current scenario in Somalia, and both of which are complex and long term issues to address. In the shorter term, micronutrient supplementation and food fortification and deworming have been proven both highly effective and low cost interventions. With their high benefit to cost ratio, these interventions have been identified as among the top ten cost-effective solutions to global challenges (Copenhagen Consensus 2008).

In Somalia, bi annual vitamin A supplementation and deworming are currently key components of child health days, multiple micronutrient supplementation for pregnant and lactating women is available through MCH. Activities identified in this strategy aim to strengthen these existing interventions and to develop new approaches to increase coverage through novel population based strategies eg through schools and nutrition programme beneficiaries.

Another novel approach identified in this strategy is the fortification of food, in particular cereal flours. Food fortification is able to deliver nutrients to the population without requiring changes in food consumption patterns. It is usually socially acceptable, requires no change in food habits, can produce nutritional benefits for the target population quickly and is a safe, cost-effective way of reaching large target populations (WHO FAO Guidelines on Food Fortification with Micronutrients 2006). Also food fortification can provide nutrients that are not obtainable in sufficient doses from local foods, such as folic acid for the prevention of birth defects. This new area for Somalia will require preliminary work before going to scale. With nearly half the population receiving humanitarian food assistance, the fortification of grains distributed through the general food ration is a priority. Furthermore as even in a good year, Somalia imports 60% of its cereal requirement, fortification of imported cereal flours presents an important vehicle for improving the micronutrient intake of a significant proportion of the population. Fortification of flour at the community level may be a useful approach in low access areas.

64 Outcome 5 Nutrition is mainstreamed as a key component of health, WASH, livelihoods, food aid and education sectors

This outcome reflects the multiple and overlapping causes of undernutrition in Somalia which require a multi sectoral response if longer term improvement in nutritional status, survival and development are to be achieved. Providing one intervention in isolation of others minimises its potential benefits and represents a missed opportunity of contact with the population. As existing structures and capacity in Somalia are weak and limited and access to and utilisation of services low, the integration and enhancement of nutrition activities within multi sector programmes is even more paramount. In health in particular, as stated in the World Bank paper, Repositioning Nutrition as Central to Development nutrition should be “included as a core function of services and not as an adjunct activity to be implemented by lower level health professionals or only when time permits”.

Activities within this strategy are aimed at mainstreaming nutrition within government as well as non government structures. Increasing awareness within the line ministries of the importance of nutrition as a key determinant of health and development will be an important step to keeping nutrition on the agenda in Somalia in the longer term.

Outcome 6 Improved capacity and means in country to deliver essential nutrition services

The situational analysis highlights the low capacity and means in country to deliver essential nutrition services. The health system is weak and fragmented, qualified professionals have left the country or moved to the private sector. Nutrition capacity within the regional authorities is limited. Thus the need to build local capacity to respond in the short and longer term is undeniable. Ideally this would encompass all levels, all sectors, government and non government structures. The Lancet series on undernutrition highlights that “governments must build internal capacity dedicated to addressing undernutrition to achieve longer lasting changes”. In the context of Somalia this is more challenging and thus key output of this strategy is to support the development of a local body responsible for addressing nutrition issues locally while government structures emerge and develop. Capacity development is not purely about training and organisation strengthening but also about building local ownership.

The development of a nutrition capacity development strategy which is linked to the UNTP plan for capacity development is an important step to identifying priorities and advocating for funding. Capacity development is needed not specifically in technical competencies but in cross cutting issues of work management, community mobilisation, team building, adopting an ethical approach, professional development. The aim is not to develop a dedicated body of highly specialised nutritionists but instead to develop relevant nutrition skills among all health workers and programmes staff from all sectors including community workers, agricultural extension workers, school teachers. Thus working with pre service training institutions for the incorporation of appropriate nutrition training modules into existing professional training curricula is a priority. The development of regional training/mentoring cells is an innovative approach to overcome challenges of limited access and supervision capacity on the ground and high staff turn over, while creating an enabling environment for partners to operate effectively is for many organisations on the ground with very limited access to resources, an important first step.

65 Annex 4 Proven Effective interventions for maternal and child malnutrition (Taken from The Lancet Series on Maternal and Child Undernutrition Executive Summary January 2008)Annex 4 Proven Effective Interventions for Malnutrition and Child Malnutrition

Sufficient evidence for

implementation in all 36 countries

Maternal and birth outcomes

Iron folate supplementation

Maternal supplements of multiple micronutrients

Maternal iodine through iodisation of salt

Maternal calcium supplementation

Interventions to reduce tobacco

consumption or indoor air pollution

Newborn babies

Promotion of breastfeeding (individual

and group counselling)

Infants and children

Promotion of breastfeeding (individual

and group counselling)

Behaviour change communication for

improved complementary feeding*

Zinc supplementation

Zinc in the management of diarrhoea

Vitamin A fortification or supplementation

Universal salt iodisation

Handwashing or hygiene interventions

Treatment of severe acute malnutrition

Evidence for implementation in

specific situational contexts

Maternal supplements of balanced

energy and protein

Maternal iodine supplements

Maternal deworming in pregnancy

Intermittent preventive treatment for malaria

Insecticide-treated bednets

Neonatal vitamin A supplementation

Delayed cord clamping

Conditional cash transfer programmes

(with nutrition education)

Deworming

Iron fortification and supplementation programmes

Insecticide-treated bednets

66 Annex 5 Copenhagen Consensus 2008: results

RANK SOLUTION1 Micronutrient supplements for children (vitamin A and zinc)2 The Doha development agenda3 Micronutrient fortification4 Expanded immunisation coverage for children 5 Biofortification6 Deworming and other nutrition programmes at school7 Lowering the price of schooling8 Increase and improve girl’s schooling9 Community based nutrition promotion10 Provide support for women’s reproductive role (Ref Horton et al 2008)

67 Annex 6 How Malnutrition affects achievement of MDGs

Goal Nutritional Effect

Annex 6 How malnutrition affects achievement of the MDGs

GOAL

Goal 1: Eradicate extreme poverty and

hunger

Goal 2: Achieve universal primary education

Goal 3: Promote gender equality and

empower women

Goal 4: Reduce child mortality

Goal 5: Improve maternal health

Goal 6: Combat HIV/AIDS, malaria and other diseases

Source: World Bank paper:

Repositioning Nutrition as Central to Development

NUTRITION EFFECT

Malnutrition erodes human capital

through irreversible and

intergenerational effects on cognitive and physical development

Malnutrition affects the chances that a child will go to school, stay in school

and perform well

Antifemale biases in access to food,

health, and care resources may result

in malnutrition, possibly reducing women’s access to assets. Addressing

malnutrition empowers women more

than men.

Malnutrition is directly or indirectly

associated with most child deaths and

it is the main contributor to the burden of disease in the developing world

Maternal health is compromised by malnutrition which is associated with

most major risk factors for maternal

mortality. Maternal stunting and iron

and iodine deficiencies particularly pose serious problems

Malnutrition may increase risk of HIV transmission, compromise

antiretroviral therapy and hasten onset

of full-blown AIDS and premature

death. It increases the chances of tuberculosis infection resulting in

disease and also reduces malaria

survival rates

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