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Nutridash 2013 [ Global RepoRt on the pilot YeaR ]

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N U T R I D A S H 2 0 1 3 [ G l o b a l R e p o R t o n t h e p i l o t Y e a R ] 0 2

AckNowleDgemeNTS

We are grateful to the UNICEF nutrition staff and focal points at the country and regional levels as well as government staff for their enormous contribution to this exercise. We also extend special thanks and recognition to Mr. Paul Gideon Jones for his contribution to the development of the web-based NutriDash

platform and database.

Additional thanks are given to the organizations that helped develop the questionnaires and coordinate data entry: Action Against Hunger, the Home Fortification Technical Advisory Group, the International Council for the Control of Iodine Deficiency Disorders Global Network, Global Alliance for Improved Nutrition, Helen Keller International, Médecins sans Frontières, the Micronutrient Initiative, SPRING (Strengthening Partnerships, Results, and Innovations in Nutrition Globally, sponsored by the United States Agency for International Development), U.S. Centers for Disease Control and Prevention, the World Food Programme and the World Health Organization.

We are also grateful for the contributions of funding from the Gates Foundation, the Centers for Disease Control and Prevention and the United States Fund for UNICEF.

We wish to especially recognize governments, specifically the state, regional and provincial ministry of health divisions, and the non-governmental organizations and staff who are working to improve nutrition interventions every day.

© United Nations Children’s Fund (UNICEF) December 2014 United Nations Children’s Fund (UNICEF), Nutrition Section, Programme Division 3 United Nations Plaza, New York, NY 10017, USA www.unicef.org

Woman displays her MCP (Mother child protection) card during the counselling on health and nutrition at Anganwadi centre in Namkum, Jharkhand, India.

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© UNICEF/INDA2012-00557/SinghINDIA, 2012

Cover pic: After adding MNP (Multiple Micro nutrient Powder), Marium Begum feeds Boishaki, daughter, in Bau Bazaar slum, Kochukhet neighbourhood of Dhaka, the capital of Bangladesh.

© UNICEF/BANA2009-00897/Noorani


AckNowleDgemeNTS 02

lIST of fIgUReS, TAbleS AND TexT boxeS 04

AbbRevIATIoNS 05

execUTIve SUmmARy 06

[ 1 ] INTRoDUcTIoN 09

[ 2 ] SeveRe AcUTe mAlNUTRITIoN 15

[ 3 ] INfANT AND yoUNg cHIlD feeDINg 28

[ 4 ] Home foRTIfIcATIoN wITH mIcRoNUTRIeNT PowDeRS 41

[ 5 ] SAlT IoDIzATIoN 46

[ 6 ] coNclUSIoNS & wAy foRwARD 52

ANNex I : country respondents to NutriDash 56

ANNex II : Iycf score calculator 58

ANNex III : mNP interventions by region, country, product and target age group 59

ANNex Iv : USI progamme performance score calculators 60

coNTeNTS

A woman prepares nutritional porridge over an open fire, during an information session on health and nutrition, in the village of Nabitenga, Plateau-Central Region, Burkina Faso. The session includes promotion of breastfeeding and other optimal infant feeding practices.

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© UNICEF/NYHQ2012-0262/ AsselinBURKINA FASO, 2012


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fIgUReS, TAbleS & TexT boxeS

fIgUReS

FIgURE 1.1 tracking implementation and progress along the programme results chain 12FIgURE 2.1 Countries with SaM management programmes, 2013 16FIgURE 2.2 SaM annual admissions trend, 2009 - 2013 20FIgURE 2.3 SaM regional burden, 2012, compared to programme admissions, 2013 21FIgURE 2.4 national treatment coverage, indirect estimates 23FIgURE 2.5 target area treatment coverage, indirect estimates 24FIgURE 2.6 national health Facility coverage 23FIgURE 2.7 national district coverage 24FIgURE 3.1 overview of iYCF policies, by country 30FIgURE 3.2 percentage of countries with Code and maternity protection related laws or regulations, by region 31FIgURE 3.3 percentage of health facilities with iYCF-trained health workers, 2013, by country 33FIgURE 3.4 percentage of districts with iYCF-trained health workers, 2013, by country 35FIgURE 4.1 overview of Mnp programmes globally, 2013 42FIgURE 4.2 percentage of Mnp interventions (n=59) integrated into other broader programmes, 2013 43FIgURE 4.3 number of Mnp interventions implemented for each target age group in 2011 and 2013 44FIgURE 4.4 number of participants reached in 2013 and expected to be reached in 2014 among implemented interventions by target age group 45FIgURE 5.1 percentage of countries (n = 86) with mandatory salt iodization legislation, voluntary iodization legislation, or no legislation 49FIgURE 5.2 percentage of countries with mandatory salt iodization (n=73), by salt commodities covered under the law 49

TAbleS

TABlE 2.1 Summary of global SaM management programme data, 2009–2013 17TABlE 2.2 indicators in nutriDash for SaM management bottleneck analysis 19TABlE 2.3 SaM annual admissions, children aged 6–59 months, 2009–2013 20TABlE 3.1 Key components and interventions of an iYCF strategy 28TABlE 3.2 overview of country scores for iYCF enabling environment 29TABlE 3.3 overview of country scores for integration of iYCF into the health system 32TABlE 3.4 overview of country scores for iYCF implementation in communities 34TABlE 3.5 number of countries using UniCeF community iYCF counselling package, by region 36TABlE 3.6 percentage of countries implementing iYCF activities, by type of activity 38TABlE 4.1 overview of Mnp interventions, 2011* (n=114) and 2013 (n=101), by region 43TABlE 5.1 percentage of countries, by level of enforcement of regulations for mandatory salt iodization 50TABlE 5.2 overview of country scores on USi programme performance 52

TexT boxeS

UNICEF REgIONAl ClASSIFICATIONS 14SAM MANAgEMENT CASE STUDY: Scaling up management of severe acute malnutrition in angola 26IYCF CASE STUDY the baby-Friendly Community health initiative in Uttar pradesh, india 39MNP CASE STUDY taking interventions from pilot to national scale in Kyrgyzstan 46SI CASE STUDY ethiopia’s history of commitment to eliminate iDD 53

N U T R I D A S H [ t h e 2 0 1 3 G l o b a l R e p o R t ] 0 5

AbbRevIATIoNS

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bfHI Baby-Friendly Hospital Initiative

cDc U.S. Centers for Disease Control and Prevention

cmAm community-based management of acute malnutrition

DHS Demographic and Health Surveys

gAIN Global Alliance for Improved Nutrition

Hf-TAg Home Fortification Technical Advisory Group

HmIS Health Management Information System

IccIDD International Council for the Control of Iodine Deficiency Disorders

Iycf infant and young child feeding

kIo3 potassium iodate

mIcS Multiple Indicator Cluster Surveys

mNP micronutrient powder

Ngo non-governmental organization

QA quality assurance

Qc quality control

RUTf ready-to-use therapeutic food

SAm severe acute malnutrition

SI salt iodization

SUN Scaling Up Nutrition (Movement)

UNIcef United Nations Children’s Fund

USI universal salt iodization

wHo World Health Organization


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execUTIve SUmmARy

oveRvIew of THe NUTRIDASH

More than ever, investing in nutrition – especially early in life – is seen as a key development priority to benefit global welfare.1 As of October 2014, 54 countries have joined the Scaling up Nutrition (SUN) Movement. With this increased attention, more resources are being deployed to improve the scope and reach of nutrition interventions. However, quality routine data on the reach and progress of programmes to support programme improvement has not always been systematically and holistically captured at the country level or collated at the global level.

Responding to this critical data and information gap, UNICEF, together with its partners, created the Nutrition Dashboard (NutriDash) in 2013. This web-based database builds on and expands previous efforts to strengthen nutrition information systems and collate country-level programme output data. NutriDash aims to support programme management, advocacy and resource mobilization; in addition, through the internal supply forecasting module, NutriDash is designed to support countries with supply projections to ensure timely delivery of globally-ordered supplies and products. The system also aims to support the selection of key nutrition-related indicators to include in routine information systems at country level, and to foster government ownership and sustainability of the collection and use of this information.

The NutriDash online database and detailed global, regional and country reports are available to UNICEF staff for this pilot year. This 2013 Global Report outlines the objectives of the Nutrition Dashboard (NutriDash) and the methodology used. It summarizes the key aggregated findings from the pilot data collection, aiming to reach decision makers and global actors involved in any of the four2 programme areas:

[ 1 ] Management of severe acute malnutrition (SAM)[ 2 ] Infant and young child feeding (IYCF)[ 3 ] Home fortification with micronutrient powders (MNP)[ 4 ] Salt iodization (SI)

1 United Nations Children’s Fund, ‘UNICEF’s Approach to Scaling Up Nutrition Programming for Mothers and Their Children’, UNICEF, New York, forthcoming in 2014.2 Vitamin A supplementation, another significant UNICEF-supported intervention, has a long-established information collection and reporting process that is currently separate from NutriDash.

A health worker at an outpatient nutrition centre in the town of Mousoro, Bar-El-Ghazel Region, in Chad, completes paperwork to have 1-year-old Achta Zaccaria admitted to a nearby therapeutic feeding centre.

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© UNICEF/NYHQ2010-1171/gangaleCHAD, 2010


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2 Global Vitamin A data is currently collected by UNICEF through a separate process, which will in the future be incorporated into the NutriDash3 It is currently accessible for UNICEF staff only

key fINDINgS AND ReSUlTS of THe 2013 DATA collecTIoN

The tracking of global information in these four areas is at different stages. For management of SAM, this exercise builds on previous efforts to track important trends. For IYCF and MNP, building on previous initiatives, this year represents an opportunity to set a baseline for many indicators not previously collected. For salt iodization, which is a more mature programme, NutriDash presents an opportunity to more closely examine the components of SI programmes as implemented at the country level. Key results from 2013 are presented below, according to the four

main areas of data collection: (1) overview of the programmes; (2) enabling environment; (3) implementation; and (4) monitoring and evaluation.

oveRvIew AND STATUS of PRogRAmmeS For each programme area, the number of countries implementing these programmes has increased during the past few years. For IYCF, 80 countries reported implementing programmes (up from 65 as reported in the 2010-2011 assessment report). For management of SAM, there are an estimated 75 countries with programmes (of which 67 submitted data to NutriDash in 2013). Between 2011 and 2013 the number of countries implementing MNP interventions has doubled from 22 to 43 countries. Currently, these 43 countries are implementing a total of 61

MNP interventions. An additional 21 countries are planning to start MNP interventions in 2014 – of which, 16 countries are in East Asia and the Pacific. With regard to salt iodization, around 23 per

cent of countries (17 out 73) reported having started their programme before 1990, 48 per cent of countries in the 1990s, and 27 per cent after 2000.

eNAblINg eNvIRoNmeNTIn 82 per cent of countries (58 out of 71), nutrition is articulated as a priority in the country’s national development strategy/plan. For SAM, 59 countries (of 67 reporting) have SAM management as part of the national health and nutrition policies. However, of these, 29 countries do not allocate any funding to SAM management within the national budgets – meaning that this intervention globally is still predominantly funded by the United Nations, non-governmental organizations and donors. Just 15 countries have SAM management within their national policy and allocate funds for both RUTF and programming within the Government national budgets.

For IYCF, 70 out of 80 countries reported to have an IYCF policy, but only 29 countries have laws that reflect the full provisions of the International Code of Marketing of Breast-milk Substitutes. While 86 per cent of countries (69 out of 80) have maternity protection legislation in place, the duration and amount of paid maternity leave, availability of breastfeeding rooms in the workplace and provision for breastfeeding breaks need greater attention. Regarding SI programmes, 85 per cent of countries (73 out of 86) have passed legislation that makes it mandatory to iodize salt.

ImPlemeNTATIoN AND ReAcHOne of the innovations of NutriDash is to compile globally the number of people who receive nutrition services. This is more easily quantified where there is a supply component to the programme as the supply input can be cross-tabulated with the reporting output in terms of numbers of people reached. Therefore the number of children being treated for SAM and reached with MNP (through certain delivery platforms) is more easily tracked and reported than recipients of IYCF services.

In 2013, 2.91 million children were reached with management of SAM services. While this represents an increase from 2012 (2.67 million children), the rate of increase of global SAM admissions has slowed compared to the expansion from previous years (2009–2011 and 2011–

Between 2011 and 2013 the number of countries

implementing MNP interventions has doubled from 22 to 43 countries

In 2013, 2.91 million children were reached with

management of SAM services



2012). While country level bottlenecks continue to be identified and addressed, it is clear that SAM treatment must be scaled up dramatically in order to better address the global burden (17 million children according to the Joint WHO-UNICEF 2013 estimates). At the same time, there is a clear need to reduce the overall SAM burden with preventive measures so that there are less children needing treatment in the first place.

For MNP, currently, more than 3 million are being reached through interventions, with an estimated reach of up to 12 million in 2014. Globally it is now estimated that about three quarters of households consume adequately iodized salt.3

moNIToRINg / INfoRmATIoN NutriDash has filled a critical global gap in programme output information. As a system, it can

help support all levels (country, regional and global) with programme management, advocacy and resource mobilization. Particularly for improving programme assessment and informing decision-making, NutriDash is aligned with UNICEF’s strategic direction towards mainstreaming programme bottleneck analysis and includes many of these indicators according to the determinant framework UNICEF uses. Including these indicators not only helps analysis, but also promotes the use of these indicators at country level and the utilization of bottleneck analysis as part of country programming.

NutriDash has also helped to provide a global overview on the strength of nutrition information systems. As a first step in analysis, data gaps indicate areas where data collection requires

improvement. NutriDash also collected data on nutrition information systems in countries. For IYCF, 60 per cent of countries (48 out of 80) reported that they are monitoring at least one IYCF indicator as part

of the national health information system. However, only 38 per cent of countries (30 out of 80) conduct routine monitoring of IYCF at the community level. Sixty-four per cent of countries (43 out of 67) reported that the HMIS collects at least one SAM management indicator, with 40 per cent (27 out of 67 countries) reporting that multiple indicators are collected through HMIS. For MNP and SI programmes, qualitative information collected on key challenges highlighted that information is a critical issue that requires strengthening moving forward.

3 United Nations Children’s Fund, The State of the World’s Children 2015: Executive Summary, UNICEF, New York, November 2014, p. 47; available at: www.unicef.org/publications/index_77928.html.

Nutridash has helped to provide a global

overview on the strength of nutrition

information systems

coNclUSIoNS AND wAy foRwARD

Gaps in policy or programming will require further analysis and it is hoped that the data collected and additional research and analysis will help with the identification of programme barriers and corrective actions across regions and countries. UNICEF’s new global guidance on scaling up nutrition programming, which will soon be rolled out, is a first step towards addressing some of the issues that will require both nutrition-specific and nutrition-sensitive interventions.

For NutriDash as a global information system, the next round of data collection will take place in early 2015 and will build on this pilot year in order to streamline and improve the system moving forward. There are plans to further enhance the utility of the database and internal planning function of the system to be even more useful to countries in looking ahead.


[ 1 ] INTRoDUcTIoN

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4 Black, Robert E., et al., ‘Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries’, Lancet, vol. 382, no. 9890, 3 August 2013, pp. 427–451; and Victora, Cesar G., et al., ‘Maternal and Child Undernutrition: Consequences for adult health and human capital’, Lancet, vol. 371, no. 9609, 26 January 2008, pp. 340–357.5 Joint Child Malnutrition Estimates (UNICEF/WHO/World Bank), 2013, http://data.worldbank.org/child-malnutrition/regional-wasting-prevalence-and-the-who-severity-levels.6 United Nations Children’s Fund, ‘UNICEF’s Approach to Scaling Up Nutrition Programming for Mothers and Their Children’, UNICEF, New York, forthcoming in 2014.

bAckgRoUND AND PURPoSe of THIS RePoRT

Despite increased attention to undernutrition, nutritional deficiencies remain a devastating and multifaceted problem. Undernutrition results in increased morbidity, mortality, cognitive delays and losses, long-term disability and poor health into adulthood – impacting the next generation and hindering the overall social and economic development of nations.4 Globally, there are 161 million children under 5 years old who are chronically undernourished (stunted) and 51 million who suffer from wasting (low weight-for-height).5

Children’s nutritional status can be improved by many factors, including the infectious disease burden; access to nutritious, micronutrient-rich foods; adequate and accessible health care and services; a healthy environment; and education and knowledge. Therefore, integrated strategies that combine nutrition-specific interventions and nutrition-sensitive approaches are needed to bring about sustainable improvements in nutrition programmes.

More than ever, investing in nutrition – especially early in life – is seen as a key development priority to benefit global welfare.6 As of October 2014, for example, 54 countries have joined the Scaling up Nutrition (SUN) Movement. UNICEF, working with national governments and in partnership with others, is committed to improving the nutritional status of children and women. By scaling up nutrition programming and improving the performance of our programmes, we can more effectively contribute to national efforts to accelerate progress. This requires strengthening information systems to ensure effective monitoring and evaluation and learning in order to keep improving nutrition programming.

The 2013 Global Report outlines the objectives of the Nutrition Dashboard (NutriDash) and the methodology used. It then summarizes the key findings in each of four modules from the pilot data collection:

[ 1 ] Management of severe acute malnutrition (SAM)[ 2 ] Infant and young child feeding (IYCF)[ 3 ] Home fortification with micronutrient powders (MNP)[ 4 ] Salt iodization (SI)

The NutriDash online database with country-specific and aggregated data is currently accessible to UNICEF staff, for this pilot year. This Global Report on the Pilot Year provides an aggregated descriptive overview of SAM management, IYCF, MNP and SI programmes – and aims to reach decision makers and global actors involved in any of the four programmes.


7 www.who.int/nutrition/gina/en8 World Health Organization, Everybody’s Business: Strengthening health systems to improve health outcomes – WHO’s framework for action, WHO, Geneva, 2007; available at: www.who.int/healthsystems/strategy/en.

oveRvIew of globAlly AvAIlAble NUTRITIoN DATA

The nationally representative Demographic and Health Surveys (DHS) and the Multiple Indicator Cluster Surveys (MICS) led by UNICEF have helped build a growing body of information on the nutritional status of people in many low- and middle-income countries. This includes data related to acute malnutrition, infant and young child feeding, micronutrients and consumption of adequately iodized salt. Additionally, limited data on certain nutrition interventions in some countries are collected through initiatives such as the Global database on the Implementation of Nutrition Action7 managed by the World Health Organization (WHO).

Outside of the above initiatives, however, quality, routine data on the coverage and progress of programmes for programme improvement are not always systematically and holistically captured and reported at the country, regional and global levels. Programme performance data is needed not only for programme management, but also to support advocacy and resource mobilization. It is clear that strong monitoring and reporting of programme performance requires robust and quality routine information systems, primarily at country but also at regional and global levels. This is the gap that NutriDash seeks to address.

Prior to 2013, UNICEF and its partners collected programmatic data on SAM management, IYCF, MNP and SI through various ad hoc paper or email surveys or online platforms, publishing results in separate reports. Below is a summary of previous data collection initiatives in the programme areas now covered by NutriDash.

SAm mANAgemeNT: In 2009–2010, UNICEF worked with Valid International to conduct a mapping of SAM management programmes globally. The Excel-format 2010 Global SAM Mapping Review questionnaire collected a wide range of qualitative and quantitative information, based on WHO’s Framework for Action to strengthen health systems.8 This exercise provided the baseline to inform subsequent data collection exercises. In 2011, UNICEF created a more concise version of the Excel questionnaire, known as the ‘Global SAM Treatment Update’, which focused more on quantitative data.

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2007; available at: www.who.int/healthsystems/strategy/en.

Toma holds her 9 month old daughter Sadia, while a health worker measures her upper arm circumference at the UNICEF supported Bitkine outpatient therapeutic feeding center in the town of Bitkine, Guera province, Chad.

© UNICEF/UKlA2012-00752/AsselinCHAD, 2012


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In 2012, a concerted effort was made to improve the SAM management data gathering system, and an online data capture and reporting system – the Global SAM Management Update – was developed. The questionnaire was refined and a reporting output system was developed to capture key data output components. Specific outputs were selected for presenting in the internal online reporting pages and in the external consolidated publication report.

Iycf: In 2010–2011, UNICEF undertook a major assessment of the scope and scale of programmes for both breastfeeding and complementary feeding in 65 countries. A key finding was that a standard menu of global indicators to measure the implementation strength of IYCF needed to be developed and consensus achieved on their feasibility and use.9 This was, in part, addressed through the formulation of the NutriDash IYCF module, but further work is required to take this forward.

mNP: In 2011, UNICEF and the International Micronutrient Malnutrition Prevention and Control Programme at the U.S. Centers for Disease Control and Prevention (CDC) conducted a global assessment of home fortification interventions with assistance from the Home Fortification Technical Advisory Group (HF-TAG).10 This assessment mapped the status of interventions related to MNP, lipid-based nutrient supplements and other complementary food supplements around the world.

Staff at UNICEF headquarters and regional focal points at partner agencies contacted representatives in 152 countries and invited them to participate in the global assessment by responding to self-administered questionnaires available in English, French and Spanish. Since 2011, many of the MNP interventions have increased in scale and new ones have started. Due to the rapid expansion of MNP programmes, a decision was made that NutriDash would start collecting information on MNP in 2013.

SI: The proportion of households consuming adequately iodized salt has been collected through DHS and MICS since the late 1990s and is collated in the UNICEF global database.11 However, NutriDash is the first platform to conduct a consolidated global assessment of SI programme components.

9 United Nations Children’s Fund, Infant and Young Child Feeding Programming Status: Results of 2010–2011 assessment of key actions for comprehensive infant and young child feeding programmes in 65 countries, UNICEF, New York, April 2012.10 UNICEF and CDC, Global Assessment of Home Fortification Interventions 2011, Home Fortification Technical Advisory Group, Geneva, 2013; available at: www.hftag.org/resource/global-assessment-of-home-fortification-interventions-2011-pdf.11 Data on coverage of adequately iodized salt can be accessed at UNICEF Data, www.data.unicef.org.

It is clear that strong monitoring and reporting

of programme performance requires

robust and quality routine information

systems



objecTIveS of NUTRIDASH

The importance of stronger routine monitoring to review results on a more frequent basis for programme improvement has gained increased recognition. NutriDash aims to strengthen routine monitoring and reporting primarily at global and regional levels, but also at country level. Programme performance monitoring includes a mix of indicators along the results chain, spanning from inputs to impact, as shown in figure 1.1. The indicators are selected for each programme as deemed most relevant to the nature and maturity of the programme.

f I g U R e 1 . 1

The overall objective of NutriDash is to systematize and harmonize data collection in key nutrition programme areas. By offering one web based platform and database, it seeks to efficiently support UNICEF country offices by visually presenting relevant nutrition programme data over time, in order to:

● Inform programme planning and design, including supply forecasting for nutrition commodities.● Assess nutrition programme performance, including the identification of bottlenecks.● Strengthen national Health Management Information Systems (HMIS), particularly through providing guidance on which indicators to consider for routine inclusion.● Support reporting, decision making, advocacy and resource mobilization at the country, regional and global programme levels.

INPUTS

Political commitment: laws, policies and charters

Financial resources: domestic and external

Human resourcesSupplies

AcTIvITIeS

Service provision, communication, coordination, and monitoring and evaluation

oUTPUTS

Geographical coverage: availability and access to services and products, (depending on intervention); exposure to messages

oUTcomeS

Population coverage: population using the service or product, or applying the messages communicated

ImPAcT

Nutrition status, e.g., as defined by World Health Assembly targets and other international and national targets

NUTRIDASH

On an annual basis, NutriDash captures country-level nutrition information on four intervention areas (modules) as implemented by all stakeholders, including UNICEF:

mANAgemeNT of SeveRe AcUTe mAlNUTRITIoN (SAM)

INfANT AND yoUNg cHIlD feeDINg (IYCF)

Home foRTIfIcATIoN wITH mIcRoNUTRIeNT PowDeRS (MNP)

SAlT IoDIzATIoN (SI)

DATA ARe USeD To: identify bottlenecks, guide action, provide information and support, connect stakeholders, communicate effectively, and support planning and procurement

1 2 3 4

NATIoNAl SURveyS

Impact-level data, and limited outcome-level data, are collected mainly through household surveys such as MICS and DHS

TRAckINg ImPlemeNTATIoN AND PRogReSS AloNg THe PRogRAmme ReSUlTS cHAIN



NUTRIDASH meTHoDology

NutriDash functions as an integrated knowledge management platform for comprehensive information on key nutrition-specific interventions. It consists of a data capture side in the form of questionnaires, and a reporting side that automatically displays the captured information for each country, as well as at the regional and global levels.

The 2013 data collection exercise was the pilot round of NutriDash and encompassed four programme areas: SAM management, IYCF, MNP and SI. With the exception of the SAM management module, which already had an online data collection system in place, the modules required developing a new online system and used different methodology compared to previous years.

The four NutriDash modules correspond to nutrition programmes that are at the core of UNICEF’s work, together with global partners aiming to improve the nutritional status of women and children. It is important to note that the modules do not target UNICEF programmes only, but are rather aiming to include information on all nutrition interventions happening in the country, whether supported by UNICEF or not.

Vitamin A supplementation, another significant UNICEF-supported intervention, has a long-established information collection and reporting process that is currently separate from NutriDash. Plans are in place to gradually expand the NutriDash platform to incorporate this and other programme areas that are relevant for UNICEF and partners.

DATA collecTIoNIn 2013, the questionnaires for each module were developed in English. Each questionnaire was developed in partnership with other global partners and experts, and subsequently shared with UNICEF regional and country offices for further refinement. The MNP questionnaire, for example, benefited from a strong collaboration with the CDC and consultation with HF-TAG, and for the SI questionnaire, the ICCIDD Global Network was an important collaborator. To facilitate data collection, instructions for the NutriDash platform were sent to nutrition/health staff in every UNICEF country office, plus the three area offices covering the Caribbean islands, the Pacific islands and the Gulf States, in December 2013.

A total of 158 countries were targeted for data collection. UNICEF headquarters and the seven regional offices were tasked with providing guidance and follow-up. For the SAM management and IYCF modules, data were entered exclusively by UNICEF staff; for the MNP module, data were entered by government, non-governmental organizations (NGOs) or other partners for those interventions that are not supported by UNICEF; for the SI programme both UNICEF and the Global Alliance for Improved Nutrition (GAIN) were given access to enter data and in some countries government entered data directly.

Data collection related to programming in 2013 occurred between December 2013 and May 2014. For all four modules, UNICEF country offices were strongly encouraged to gather all stakeholders together – particularly government counterparts – and enter data jointly, using this opportunity to discuss the programmatic context in their country.

DATA ARe USeD To: identify bottlenecks, guide action, provide information and support, connect stakeholders, communicate effectively, and support planning and procurement

QUAlITy coNTRol, DATA cleANINg AND ANAlySISData collection, cleaning and analysis were performed using Microsoft Excel. After input, data were verified and reviewed to identify inconsistencies, duplications and gaps within and across the four NutriDash modules, and also against past data collected through other systems or surveys. When necessary, UNICEF headquarters and regional colleagues communicated with the country contact to clarify or confirm the data points. In total, 129 countries required some sort of follow-up, ranging from minor fact checking to major substantive queries and subsequent changes across the programme modules.

Issues raised during the pilot ranged from general questions on using the online system for the first time to specific questions about modules or individual items. Based on the NutriDash pilot experience, the information technology system and quality of data being submitted should improve over time as the process for data input is streamlined, guidance is improved, and the automatic data validation is strengthened.

DATA RePoRTINgIn both the present global report as well as in the web-based NutriDash report, the denominator varies across indicators. Although each country was invited to respond to all modules, not all programme areas are relevant for all countries. Denominators exclude countries that did not respond, some of which might not have responded to a specific module because they do not implement that particular programme.

The findings are presented as proportions, and the denominators are indicated each time. Findings must be interpreted in light of the limitations of the data, including the low response for some modules and some questions.



U N I c e f R e g I o N A l c l A S S I f I c AT I o N S

ceNTRAl AND eASTeRN eURoPe AND THe commoNweAlTH of INDePeNDeNT STATeS (cee/cIS):

Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, georgia, Kazakhstan, Kosovo, Kyrgyzstan, Montenegro, Republic of Moldova, Romania, Serbia, Tajikistan, The former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, Uzbekistan

eAST ASIA AND THe PAcIfIc (eAPR):

Cambodia, China, Cook Islands, Democratic People’s Republic of Korea, Fiji, Indonesia, Kiribati, lao People’s Democratic Republic, Malaysia, Marshall Islands, Micronesia (Federated States of), Mongolia, Myanmar, Nauru, Niue, Palau, Papua New guinea, Philippines, Samoa, Solomon Islands, Thailand, Timor-leste, Tokelau, Tonga, Tuvalu, Vanuatu, Viet Nam

eASTeRN AND SoUTHeRN AfRIcA (eSAR):

Angola, Botswana, Burundi, Comoros, Eritrea, Ethiopia, Kenya, le-sotho, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Somalia, South Africa, South Sudan, Swaziland, Uganda, United Republic of Tanzania, Zambia, Zimbabwe

lATIN AmeRIcA AND THe cARIbbeAN (lAcR):

Anguilla, Antigua and Barbuda, Argentina, Barbados, Belize, Bolivia (Plurinational State of), Brazil, British Virgin Islands, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador,

El Salvador, grenada, guatemala, guyana, Haiti, Honduras, Jamaica, Mexico, Montserrat, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint lucia, Saint Vincent and the grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, Uruguay, Venezuela (Bolivarian Republic of)

mIDDle eAST AND NoRTH AfRIcA (meNAR):

Algeria, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, lebanon, libya, Morocco, Oman, Qatar, Saudi Arabia, State of Palestine, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, Yemen

SoUTH ASIA (RoSA): Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri lanka

weST AND ceNTRAl AfRIcA (wcAR):

Benin, Burkina Faso, Cabo Verde, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Equatorial guinea, gabon, gambia, ghana, guinea, guinea-Bissau, liberia, Mali, Mauritania, Niger, Nigeria, Sao Tome and Principe, Senegal, Sierra leone, Togo

SUb-SAHARAN AfRIcA:

All countries in Eastern and Southern Africa, and West and Central Africa, plus Djibouti and the Sudan



12 Joint Child Malnutrition Estimates (UNICEF/WHO/World Bank), 2013, http://data.worldbank.org/child-malnutrition/regional-wasting-prevalence-and-the-who-severity-levels.

[ 2 ] SeveRe AcUTe mAlNUTRITIoN

bAckgRoUND

The management of severe acute malnutrition (SAM) is critical for child survival and is a key cost-effective component of the scaling up nutrition framework for addressing undernutrition. Globally in 2013, an estimated 51 million children under 5 years old were wasted and 17 million were severely wasted. Approximately 59 per cent of all severely wasted children lived in East and South Asia, and 32 per cent in sub-Saharan Africa.12 Severe acute malnutrition (SAM) is common in rapid onset emergencies and chronic emergencies as well as non-emergency situations.

UNICEF is a leading organization supporting the scaled-up implementation of community-based management of SAM, providing technical support and capacity-building for ministries of health and NGOs involved in treating children with SAM and engaging with the World Food Programme and other partners to link to services to address moderate acute malnutrition.

Globally, UNICEF remains the main procurer of ready-to-use therapeutic food (RUTF), procuring approximately 80 per cent of global needs, in addition to procuring the bulk of therapeutic milk (F-75, F100), which is also essential for SAM treatment. UNICEF continues to support the local production of RUTF and has diversified its supplier base to include manufacturers in 15 countries.

Building on the 2012 Global SAM Management Update, the aim of this NutriDash module is to support supply forecasting for and provide an overview of the scope, scale and implementation of SAM management programming globally.

fINDINgS

In 2013, 67 countries responded to NutriDash as having SAM treatment programmes, UNICEF or non-UNICEF supported. In addition, 8 countries did not submit data to NutriDash in 2013 but are known to have SAM management programmes from past data collection exercises, such as UNICEF country office annual reports or the 2009–2012 mapping. Thus, there are an estimated 75 countries with SAM management programmes, as illustrated in figure 2.1.



f I g U R e 2 . 1

coUNTRIeS wITH SAm PRogRAmmeS - 2013*

Among the countries that reported SAM management programmes to NutriDash, 49 per cent (33 out of 67) are located in sub-Saharan Africa – which is also the region with the greatest number of admissions for treatment, at 2.18 million of 2.91 million, or 75 per cent.

Data were also gathered regarding the type of service: inpatient, which is defined as hospital-based treatment, or outpatient treatment at the health facility or community level. Fifty-six countries that have SAM management programmes provided both outpatient and inpatient services, with the remainder providing only inpatient service. None of the countries that responded to NutriDash 2013 provided outpatient-only services.

*Of the 158 countries surveyed, 75 have a SAM management programme

SAm management Programmes in 2013 (as reported in NutriDash)

SAm management programme (but NoT reported in NutriDash in 2013)

No SAm management programme reported

Not targeted

This map is stylized and not to scale. It does not reflect a position by UNICEF on the legal status of any country or territory or the delimitation of any frontiers



TA b l e 2 . 1

SUmmARy of SAm PRogRAmme DATA - 2009 To 2013

TRAckINg PRogReSS fRom 2009–2013Overall, there has been an increase in the number of countries reporting SAM treatment programming compared to the baseline CMAM mapping in 2009, when 65 countries reported that they had some form of acute malnutrition management programme.

● In 2011, 55 countries responded through the SAM Global Treatment Update that they had a SAM management programme; in addition, 10 countries were known to have programmes, either due to submissions to UNICEF internal reporting or having answered positively to the 2009 mapping.● In 2012, 62 countries responded through the SAM Global Management Update that they had a SAM management programme; in addition, 5 countries were known to have programmes through internal reporting or mapping.● As of 2013, the total number of countries implementing SAM management services reached 75.

INDICATOR 2009 2011 2012 2013

# Countries Implementing SAM Services 65 65 67 75

# of reported cases admitted to treatment 1,035,771 1,961,722 2,662,712 2,909,410

Performance Indicators:

# of countries with cure rate >= 75% 21 countries (40%) 21 countries (34%) 30 countries (73%) 29 countries (74%)

# of countries with defaulter rate < 15% 26 countries (49%) 20 countries (33%) 25 countries (68%) 31 countries (79%)

[# of countries with incomplete or missing data] 23 countries (38%) 28 countries (42%)

Programme treatment coverage (admissions/SAM burden):

# of countries able to provide information on

coverage (includes every country able to report 53 countries 53 countries

on one or more aspect of treatment coverage –

national, target area or implementation progress)

>50% national treatment coverage 19 countries 15 countries

geographical coverage/access (# of health facilities with SAM management services/total # of health facilities):

# of countries able to provide information

on health facilities 28 countries (48%) 49 countries (82%) 46 countries (69%)

Mean geographical coverage

(# of health facilities delivering SAM services/

total national # of health facilities) 33% 43% 42%

Procurement of RUTF 6,231 metric tons 27,000 metric tons 29,000 metric tons 33,000 metric tons

No reliable data for intra-country comparison (as too much variation between methods of calculation)





eNAblINg eNvIRoNmeNTOf 67 countries reporting to NutriDash in 2013, 59 have included SAM treatment as part of the national health and nutrition policies. However, 29 of these countries did not allocate any funding to SAM management within the national budgets – meaning that this intervention remains predominantly funded by United Nations agencies, NGOs and donors.

Only 15 countries have incorporated SAM management within their national policy and at the same time allocate funds for both programming and RUTF supplies within the national budget. Further work is therefore required to promote and support national expenditure on SAM programming, including commodities.

INTegRATIoN of SAm INTo NATIoNAl HeAlTH SySTemSTo track the integration of SAM management programming into national health systems, a few questions were asked in NutriDash 2013. Although comparison to previous years is problematic since questions for the 2011 and 2012 Global SAM Updates were largely posed differently, a summary of the findings can be extrapolated for the following indicators:

● Between 2012 and 2013, the number of countries reporting that SAM management is part of national policies/strategies increased from 51 to 59.● The number of countries incorporating SAM management indicators in the HMIS increased from 14 in 2009 to 16 in 2011, 41 in 2012 and 43 in 2013.● The number of countries reporting that RUTF is part of the essential supplies list rose from 21 countries in 2012 to 25 in 2013.

boTTleNeck ANAlySISNutriDash 2013 was inclusive of indicators designed to facilitate bottleneck analysis, according to the determinants framework – enabling environment, supply, demand and quality – that UNICEF has been rolling out as part of its equity approach.13

Within this framework, the determinants in UNICEF’s model are: commodities; human resources geographical access; utilization; continuity; and effective coverage or quality.14 Information on geographical access, initial utilization, continuity and effective coverage can be tracked using the health facility and district coverage rates, admissions and performance indicators.

The indicators developed in 2013 sought to fill the gaps that were noted in previous SAM management questionnaires, particularly regarding supply (RUTF stockouts) and human resources (health workers trained on SAM management). By including supply and human resource information, a simple bottleneck analysis – as shown in Table 2.2 – can be done at the national level for each country. UNICEF and partners is undertaking piloting of integration15 of these indicators into national nutrition information systems in order to further test the indicators and promote more regular bottleneck analysis at the country level to guide programme responses.

13 United Nations Children’s Fund, ‘Narrowing the Gaps to Meet the Goals’, UNICEF, New York, 2010; available at: www.unicef.org/media/files/Narrowing_the_Gaps_to_Meet_the_Goals_090310_2a.pdf. 14 United Nations Children’s Fund, ‘Reaching Universal Health Coverage through District Health System Strengthening: Using a modified Tanahashi model sub-nationally to attain equitable and effective coverage’, Maternal, Newborn and Child Health Working Paper, UNICEF, New York, December 2013; available at: www.unicef.org/health/files/DHSS_to_reach_UHC_121013.pdf.15 ACF-UK; FANTA and HKI



In total, 22 countries provided enough data to fill all six determinants of coverage. As part of the NutriDash online reporting system, each country can review its national SAM management programme bottleneck analysis graph.

Interestingly, very few of the country graphs identified that supplies were an issue, yet this is the biggest component of a response. Preliminary feedback from the field suggests that reporting of stockouts is one of the most challenging aspects to report on within a routine information system. Therefore, more work to strengthen this area is required, and UNICEF is exploring use of the RapidPro text message technology to speed up and improve reporting of stockouts and communication of supply information.

TA b l e 2 . 2

INDIcAToRS IN NUTRIDASH foR SAm mANAgemeNT boTTleNeck ANAlySIS

DETERMINANT INDICATOR

COMMODITY % of health facilities that did not have stockouts of Ready to

Use Therapeutic Food (RUTF) in the last 3 months

HUMAN RESOURCES % of health workers who have been trained on SAM management

gEOgRAPHICAl ACCESS % of health facilities offering SAM treatment

UTIlIZATION % of children <5 with SAM who were admitted for SAM treatment

CONTINUITY % of children <5 with SAM who did NOT default from SAM treatment

QUAlITY % of children <5 with SAM who were cured

coveRAge SURveySIn conjunction with strengthening bottleneck analysis through routine data collection to identify and address issues in achieving programme coverage, UNICEF offices increasingly support collection and use of direct surveys to estimate coverage of SAM treatment, primarily at the sub-national level. In 2013, 15 countries conducted one or more direct coverage surveys, either UNICEF or non-UNICEF supported. Of these, 11 countries conducted 28 surveys and provided details on the level and the methodology of the survey. All 28 surveys were conducted at sub-national level, and 17 were conducted using the Semi-Quantitative Evaluation of Access and Coverage methodology.



ADmISSIoNSIn 2013, it was reported that 2.91 million children were admitted for treatment of SAM, as shown in Table 2.3. Of these, UNICEF supported 2.68 million admissions.

Although global admissions for SAM treatment continued to increase between 2009 and 2013 – with the focus on scaling up outpatient programmes, the rate of increase in 2013 was lower than anticipated in relation to the 2012 projections. Reasons for this deceleration include limitations in funding and political will, among others. The country-specific bottlenecks and issues are being explored further to guide action during 2015. While the expansion of treatment services and increase in admissions continues, there remains a large gap in relation to the global burden (17 million according to the Joint UNICEF-WHO estimates). While efforts to scale up SAM treatment continue, much more needs to be done to reduce the overall burden with preventative measures so that fewer children need treatment.

In 2013, the West and Central Africa region built on the successful scale-up of treatment in 2011 and 2012, which had been carried out in response to the food and nutrition and crisis in the Sahel Region. Eastern and Southern Africa, however, saw a decline in admissions of 11 per cent since 2012, with only Angola reporting a significant increase in admissions; 5 of the remaining 13 countries in the region that submitted data reported significant reductions in admissions, in the range of 125,000 fewer cases in 2013 compared to 2012. While the improving food and nutrition situation in the region in the aftermath of the 2011 Horn of Africa crisis may account for some of that variance, further analysis is needed.

f I g U R e 2 . 2

SAm ANNUAl ADmISSIoNS TReND, 2009 - 2013

AD

MIS

SIO

NS

0

3,500,000

2009

YEAR

3,000,000

2,500,000

2,000,000

1,500,000

500,000

1,000,000

2011 2012 2013

2,9

09

,41

0

2,6

65

,67

9

1,9

61

,77

2

1,0

35

,77

1



figure 2.3 illustrates the gap between the SAM burden and admissions for treatment being achieved in each region. The admissions data are the cumulative figure for the year 2013. The burden data come from the 2013 UNICEF-WHO joint estimates; however, these estimates are based on a severe wasting point prevalence, therefore they only present the SAM burden at one point in time. If a period SAM burden figure is used, the gap between annual admissions and annual burden could actually be even greater.

1

IN M

ILL

ION

S

2

0

4

5

3

7

8

6

9

10

CEE/OS East Asia & Pacific

Eastern &Southern

Africa

LatinAmerica

& Caribbean

Middle East & North Africa

South Asia West & Central Africa

f I g U R e 2 . 3

SAm RegIoNAl bURDeN, 2013, comPAReD To PRogRAmme ADmISSIoNS, 2013

2013 burden

2013 Admissions

TA b l e 2 . 3

SAm ANNUAl ADmISSIoNS, ChilDRen 6-59 MonthS, 2009 - 2013

REgION 2009 2011 2012 2013

East Asia & Pacific 5,600 12,671 31,813 33,677

Eastern & Southern Africa 414,412 806,919 890,414 790,264

latin America & Caribbean 0 21,660 28,882 19,906

Middle East & North Africa 64,124 128,647 217,935 330,865

South Asia 29,116 207,215 258,366 340,312

West & Central Africa 488,366 784,660 1,235,302 1,394,386

globAl 1,001,618 1,961,772 2,662,712 2,909,410



QUAlITy of TReATmeNTIn 2013, 2.02 million children were reported as cured, while almost 269,000 defaulted, 26,000 died and 144,000 were non-respondent out of 2.46 million discharged.

Given the standard treatment period of 45 days for a child, it should be noted that there is a time lag between admissions and exits, which can influence the numbers and account for the gap between admissions and exits. Because gaps in reporting across countries within regions potentially impact the summary indicators, reporting quality also needs to be factored into interpreting indicators of treatment quality.

The countries that were able to report on performance indicators remained virtually the same in 2012 and 2013, indicating that additional support is required to identify and address bottlenecks with reporting and data quality in these other countries.

coveRAgeAs related to NutriDash, ‘coverage’ in this document refers to indirect estimates, as opposed to direct estimates from surveys.

c ov e R A g e

Programme Treatment CoverageAs per guidance given in 2012 and 2013, indirect programme treatment coverage is calculated as follows:

Number of SAM children 6-59mo admitted in 2013

6-59m population x prevalence of SAM x incidence correction factor (i.e., burden of SAM)

In 2012, approximately one quarter of countries reported that they were aiming for countrywide scale up (75-100 per cent of districts with SAM service provision), while the majority of programmes did not report the same aim. The 2012 Global SAM Management Update Report reported national indirect treatment coverage estimates, however these figures did not adequately reflect coverage of subnational programmes given that subnational results were compared against a national burden denominator. In 2013, NutriDash was designed to capture both the national level treatment coverage figure – which is critical for understanding the nation-wide progress and remaining gap in treatment – and also to provide a nuanced, broader picture of the programme achievements relating to the geographic areas actually being covered and targets being set.

PRogRAmme TReATmeNT coveRAge:

The proportion of those children in need of SAM treatment who received treatment – measured as the proportion of admissions of children into SAM

programmes out of the burden of SAM (all SAM cases).

geogRAPHIc coveRAge*

There are two definitions of geographic coverage, measured either as the proportion of (i) districts or (ii) health facilities offering SAM treatment.

*Geographic coverage is termed “Geographic access” in UniCeF’s internal bottleneck analysis determinants framework (monitoring of results for equity strengthening [MoReS])

Although the global gap between admissions and the burden of SAM cases varies across regions, the proportional gap in South Asia indicates that further support in that region is critical to scale up treatment and prevention programmes in order to address the global burden of acute malnutrition.



TReATmeNT coveRAgefigure 2.3 presents admissions in relation to burden at regional level, and shows that treatment coverage16 remains well below the needs. In countries, the progress is more heterogeneous, and reflects different national strategies, capacities and constraints. figure 2.4 presents indirect national estimates of treatment coverage. Forty-eight per cent of countries (24 out of 50) reportedly achieved over 25 per cent coverage; 14 per cent of countries (7 out of 50) reached over 75 per cent coverage – four of these were in West and Central Africa region. These figures are comparable to those from 2012. In some countries, programmes focus on specific geographical areas. Indirect treatment coverage is higher in programme target areas, with 40 per cent of countries (20 out of 50) achieving over 50 per cent coverage, and 28 per cent achieving over 75 per cent coverage (figure 2.5). While global treatment coverage is low, many countries are achieving high rates of coverage; the experiences of these countries need to be built upon and learning transmitted to support the scaling up of programming globally. This scale up is being accompanied by continued efforts to improve data quality, and in particular estimates of country level burden.

[ 1 ] NATIONAl COvERAGE = new admissions (supported by all actors)/national burden[ 2 ] TARGET AREA COvERAGE = new admissions (supported by all actors)/target area burden (i.e., where the programme was actually operating)[ 3 ] IMPlEMENTATION PROGRESS = admissions/target caseload (i.e. the admissions over the target of SAM cases set by all actors)

f I g U R e 2 . 5

NATIoNAl TReATmeNT coveRAgeinDiReCt eStiMateS (50 CoUntRieS RepoRtinG):

no. oF CoUntRieS, peR CoveRaGe bRaCKet

TARgeT AReA TReATmeNT coveRAgeinDiReCt eStiMateS (46 CoUntRieS RepoRtinG):

no. oF CoUntRieS, peR CoveRaGe bRaCKet

925 -49%

coUNTRIeS

850 -74%

coUNTRIeS

26>24%

coUNTRIeS

coUNTRIeS 775 -100%

16>24%

coUNTRIeS

1025 -49%

coUNTRIeS

650 -74%

coUNTRIeS

1475 -100%

coUNTRIeS

f I g U R e 2 . 4

16 The indirect estimate of treatment coverage is based on admissions figure of 2.91 million 6-59 months and a global burden of 17 million 0-59 months.



geogRAPHIc coveRAgeThere are two working definitions of geographical coverage used by UNICEF, related to health facilities and districts, respectively. Because these indicators reflect different but complementary aspects of geographical reach, data for both definitions were gathered through NutriDash for 2013:

[ 1 ] (Health facility) Geographical coverage = Health-care facilities delivering treatment for SAM (national or target area)/Total number of health-care facilities (national or target area)

[ 2 ] (District) Geographical coverage = Districts delivering treatment for SAM/Total districts

This enables triangulation of the two data points, as the number of health facilities per district is not uniform within and across countries. The two indicators enable cross-tabulation across the country/target area in terms of both districts and of health facilities regarding what percentage of these are delivering services – providing a richer picture of the extent of geographical coverage within and across countries.

figure 2.6 and 2.7, compares national geographic coverage based on the two definitions of health facility coverage and district coverage. While over half of the countries reported that more than 75% of districts have SAM services, only one quarter of countries (10 out of 40) reported that more than 75% of health facilities provide SAM services. There are a number of different strategies for expanding scale of SAM treatment, including by covering all health facilities in a district before systematically initiating services in another district, or establishing SAM treatment in limited health facilities over a larger number of districts. For this reason, tracking coverage using both definitions is critical to provide an accurate country level view of progress in scaling up services.

f I g U R e 2 . 6 f I g U R e 2 . 7

NATIoNAl HeAlTH fAcIlITy coveRAge(40 CoUntRieS RepoRtinG): no. oF CoUntRieS,

peR CoveRaGe bRaCKet

NATIoNAl DISTRIcT coveRAge(44 CoUntRieS RepoRtinG): no. oF CoUntRieS,

peR CoveRaGe bRaCKet

1125 -49%

coUNTRIeS

15>24%

coUNTRIeS

8>24%

coUNTRIeS

625 -49%

coUNTRIeS

2575 -100%

coUNTRIeS

1075 -100%

coUNTRIeS

coUNTRIeS

550 -74%

coUNTRIeS 450 -74%



INTegRATINg DATA oN HIvIn 2013, data were collected on HIV testing and referral to HIV services for children receiving treatment for acute malnutrition in order to establish a baseline for the integration of SAM management and HIV services. Four countries – Cambodia, Haiti, Malawi and Zimbabwe – reported data on these indicators. In Cambodia, Haiti and Zimbabwe, all children in SAM treatment who were tested and found to be HIV-positive were also referred to treatment. However, the fact that more countries did not report demonstrates the need to strengthen data collection and reporting around this intervention area in order to better guide programme development.

SAm SUPPly foRecASTINgAnother addition to NutriDash in 2013 was the internal UNICEF SAM supply forecasting tool, which had in previous years been sent to countries in Excel form and compiled manually. The NutriDash SAM supply forecasting tool provides automated data entry pages for countries to insert their projected admissions for the next year and the current stock levels; it also generated supply needs and costs for the coming year for each country.

In total, 43 countries submitted data into the supply forecasting tool. In terms of admissions, of those countries submitting data, around 2.4 million children were projected to be reached with treatment for SAM in 2014. Supply needs of ready-to-use therapeutic food were projected at slightly more than 2 million boxes of RUTF. The difference between the figures is due to some supplies already being in the countries so only the gap (2 million boxes) is what is ordered for the coming year. As a planning tool, the supply forecast will be improved and strengthened to maximize utility for country offices, for example, bringing together data admissions and stock utilization from previous years.

coNclUSIoNSIn 2013, 2.91 million children were reached with services to manage SAM. While this represents an increase from 2.67 million children in 2012, the rate of increase of global SAM admissions has slowed compared to previous years.

It is evident that the expansion of treatment services has a long way to go to reach the estimated 17 million children who still suffer from SAM, according to the Joint UNICEF-WHO estimates – particularly in South Asia, where the gap between treatment coverage and the disease burden is particularly wide. Additionally, while efforts to scale up SAM treatment continue, much more needs to be done to reduce the overall burden with preventive measures so that less children need treatment.

Globally, increased integration of SAM treatment into national policies and strategies, and inclusion of related indicators into the HMIS, have supported increased coverage of treatment for SAM. However, continued action is required to translate this foundation into equitable provision of services for SAM management.

Nutrition information has a key role to play in SAM scale up. The 2013 SAM management module included indicators to support planning and supply forecasting, to provide a more nuanced analysis of SAM management coverage, and to enable bottleneck analysis using available information. It is envisaged that inclusion of SAM management-related indicators in NutriDash, as well as concurrent ongoing support to countries, will promote the inclusion of these indicators in national information routine reporting systems to strengthen monitoring of coverage and its bottlenecks over time.

Future work on the SAM management component of NutriDash will include refining the questionnaire to support the above, as well as strengthening the supply forecasting, based on this data collection.



Scaling up management of acute malnutrition in angolaby NelSoN beRNAbe

SAm cASe STUDy

In 2013, UNICEF supported the Government of Angola in an unprecedented scale-up of the integrated management of severe acute malnutrition. Intensive efforts by the Ministry of Health and UNICEF, with the valuable contribution of donors, made it possible to scale up SAM treatment through extension of the outpatient therapeutic programme and inpatient facilities, as well as the CMAM outreach programme. This resulted in opening 37 new inpatient and 606 new outpatient therapeutic programme centres, thereby facilitating expanded community outreach.

As of December 2013, a total of 1.97 million children were screened for acute malnutrition, with almost 74,000 treated for SAM. The table below shows the radically increased number of admissions since 2011:

UNICEF worked in collaboration with a consortium of NGOs led by World vision, in collaboration with the Ministry of Health’s nutrition section, thereby allowing for a stronger presence on the ground and better coordination with communities and local traditional leaders. The intervention “Together Against Malnutrition” created a unique advocacy momentum and opened strategic room for the gradual introduction of other key best practices – including salt iodization and use of micronutrients – and to reinforce other healthy behaviours such as exclusive breastfeeding. Continued advocacy also resulted in the procurement of ready-to-use therapeutic products by the Government of Angola, starting in August 2013.

Strengthening nutrition results and promoting an inter-sectoral approach, water, sanitation and hygiene (WASH) and nutrition interventions were integrated through the

provision of information materials on drinking water treatment and safe storage at inpatient and outpatient centres, as well as through the provision of soap for hand washing in health and nutrition centres. Key messages on WASH have been integrated into the training for more than 2,010 health staff and 2,428 community mobilizers. UNICEF also supported provincial governments in Cunene and Huila to assess affected areas and implement sanitation activities through Community-led Total Sanitation.

Despite the unprecedented scaling up of the nutrition response, several challenges remain:

● capacity of health and logistics staff at all levels requires strengthening.● frequent staff turnover affects the quality of care and service delivery.● Due to fast scaling up of the programme, there is a great need for active monitoring and supervision, refresher training sessions, support for the staff in newly opened centres, and technical support to organize monthly review meetings with the nutrition supervisors at all levels.● In order to produce long-term results, awareness-raising, behaviour change and capacity-building activities have to be consistently implemented or replicated in the central provinces, in order to foster a more gradual transition toward local and sustainable ownership.

To strengthen the quality of treatment and information flow, to match the scale-up of services, the above issues will need to be addressed moving forward, to consolidate and build upon the good work that has been undertaken in 2013.

2011 2012 2013

# OF SAM ADMISSIONS 8,076 8,775 73,910


unite for children

Ready-To-Use Therapeutic Food is being used in southern Laos to treat severe acute malnutrition. It contains high levels of easily available energy,adequate micronutrientsand high quality proteins.

© UNICEF/lAOA2011-00062/TattersalllAO PEOPlE’S DEMOCRATIC REPUBlIC, 2011


unite for children

AckNowleDgemeNTS


bAckgRoUND

Infants who are exclusively breastfed for the first six months of life are less likely to die from diarrhoea and pneumonia, the two leading killers of children under age 5. Suboptimum breastfeeding, however, still accounts for an estimated 800,000 deaths in children under age 5 annually, representing about 12 per cent of total child deaths each year.17 Data from 2011 indicate that among children born in low-income countries, only 39 per cent of infants 0–5 months old are exclusively breastfed.18

In accordance with the Global Strategy on Infant and Young Child Feeding,19 UNICEF’s goal in this programme area is to protect, promote and support optimal practices that improve maternal nutritional status and safeguard women’s health, as well as ensure good nutritional status for children. Optimal practices include initiating breastfeeding within one hour of birth, exclusive breastfeeding for the first six months of life and continued breastfeeding up to age 2 and beyond, together with safe, age-appropriate feeding of solid, semi-solid and soft food starting at 6 months of age.

A comprehensive approach to IYCF involves large-scale action at the national, health-system and community levels, including various cross-cutting strategies such as communication and context-specific actions on infant feeding in the context of emergencies and HIV, as outlined in Table 3.1.

17 Black, Robert E., et al., ‘Maternal and Child Undernutrition and Overweight in Low-Income and Middle-Income Countries’, Lancet, vol. 382, no. 9890, 3 August 2013, pp. 427–451.18 United Nations Children’s Fund, Improving Child Nutrition: The achievable imperative for global progress, UNICEF, New York, April 2013, p. 19.19 World Health Organization and United Nations Children’s Fund, Global Strategy for Infant and Young Child Feeding, WHO, Geneva, 2003, www.who.int/nutrition/publications/infantfeeding/9241562218/en. 20 United Nations Children’s Fund, Infant and Young Child Feeding Programming Status: Results of 2010–2011 assessment of key actions for comprehensive infant and young child feeding programmes in 65 countries, UNICEF, New York, April 2012.

[ 3 ] INfANT AND yoUNg cHIlD feeDINg

TA b l e 3 . 1

key comPoNeNTS AND INTeRveNTIoNS of AN Iycf STRATegy

Following the 2010–2011 comprehensive assessment of IYCF programmes in 65 countries,20 valuable lessons were learned and recommendations put forward to strengthen implementation of IYCF programmes. The aim of the NutriDash module is to build on the earlier IYCF multi-country assessment and give an updated overview of the scope, scale and implementation of IYCF programmes globally.

Source: Adapted from United Nations Children’s Fund, Programming Guide: Infant and young child feeding, UNICEF, New York, 2011, p. 32.

COMPONENT INTERVENTION

lEgISlATION ● Development and enforcement of national legislation on the marketing of breast-milk substitutes ● Development and enforcement of national legislation on maternity protection

SKIllED SUPPORT BY ● Curriculum development for IYCF - IYCF counselling and other support services THE HEAlTH SYSTEM ● Capacity development for health providers ● Institutionalization of the Baby-Friendly Hospital Initiative (BFHI)

COMMUNITY-BASED ● Establish community-based integrated IYCF counselling services COUNSEllINg & SUPPORT ● Create mother support groups for IYCF in the community

COMMUNICATION ● Communication for behaviour and social change

ADDITIONAl ● Improve the quality of complementary foods through locally available ingredients COMPlEMENTARY ● Increase agricultural productionFEEDINg OPTIONS ● Provide food-insecure populations with nutrition supplements and foods for complementary feeding ● Implement social protection schemes

IYCF IN DIFFICUlT ● HIV and infant feeding CIRCUMSTANCES ● IYCF in emergencies



Iycf meTHoDologIeSThe IYCF scores were formulated at the global level and cover four areas: monitoring and evaluation, IYCF integration in health systems, IYCF integration into community programmes, and an enabling environment. Each of these areas has a specific set of responses that are weighted to calculate a cumulative score. The scores are normalized to be scored from 0–10, with the following brackets used to determine the categories:

● INSUFFICIENT: 0–2.99 ● FAIR: 3–5.99 ● GOOD: 6–8.99 ● vERY GOOD: 9–10

Annex II provides the calculators for how these IYCF scores are obtained.

fINDINgS

Of the 158 countries that were targeted through NutriDash, 51 per cent (80 countries) responded to the IYCF module. This section provides information on the enabling environment, implementation in the health system and at the community level, and monitoring of IYCF indicators.

eNAblINg eNvIRoNmeNTThe enabling environment for IYCF is weak. For the aggregated indicator – an IYCF policy, legislation on the marketing of breast-milk substitutes and maternity protection, and IYCF in the pre-service curriculum – 41 per cent of countries (33 out of 80) scored ‘insufficient’ and an absolute minority of countries scored ‘good’ or ‘very good’, as shown in Table 3.2.

In total, 87 per cent of countries (70 out of 80) have some type of IYCF policy. Fifty-six per cent (45 out of 80 countries) have a stand-alone IYCF policy, and 31 per cent (25 out of 80 countries) have integrated IYCF into other policies such as the nutrition or child health policies. figure 3.1 provides a global overview of the policy status in countries that responded to NutriDash.

TA b l e 3 . 2

oveRvIew of coUNTRy ScoReS foR Iycf eNAblINg eNvIRoNmeNT

Country score Percentage # of countries

(n=80)

Insufficient 41% 33

Fair 56% 45

good 3% 2

Very good 0% 0



f I g U R e 3 . 1

oveRvIew of Iycf PolIcIeS by coUNTRy

At the highest policy level, it is important that the national laws and/or regulations give effect to the International Code of Marketing of Breast-milk Substitutes (the Code) and subsequent World Health Assembly (WHA) resolutions. It is also important that laws provide protection for women, including ensuring that pregnant women are not exposed to safety hazards and are given an adequate amount of paid maternity leave and breastfeeding breaks.

Standalone Iycf policy or strategy

Iycf elements are integrated into other policies

No Iycf policy or strategy

No response

Not targeted




Sixty per cent of countries (48 out of 80) have both types of laws in place, and 18 per cent (14 out of 80) are in the process of developing legislation. Overall, 68 per cent of countries (54 out of 80) have laws reflecting the Code, but only 36 per cent (29 out of 80) have laws that reflect the full provisions and 10 per cent of countries do not have laws to implement the Code at all. Maternity legislation is in place in 86 per cent of countries (69 out of 80), and the law includes the right to breastfeeding breaks in 59 per cent of these countries (41 out of 69). figure 3.2 provides details on they types of legislation, by region.

f I g U R e 3 . 2

PeRceNTAge of coUNTRIeS wITH coDe AND mATeRNITy PRoTecTIoN RelATeD lAwS oR RegUlATIoNS by RegIoN

Iycf IN THe HeAlTH SySTemAn essential part of IYCF implementation is capacity-building among health-care professionals. This includes providing pre-service training – on-the-job training that helps develop hands-on skills and is built into education/training curricula so that each new generation of health-care providers has current knowledge in IYCF.

Country responses indicate that 16 per cent of countries (13 out of 80) do not have any pre-service training on IYCF, and 49 per cent (39 out of 80) have minimal pre-service training for either medical doctors, or nurses and other health professionals. Only 18 per cent of countries (14 out of 80) – predominantly in CEE/CIS and Latin America and the Caribbean – have comprehensive IYCF training in the pre-service curricula for either medical doctors or nurses and other health professionals, and 4 per cent (3 out of 80) have comprehensive training for medical doctors, nurses, and other health professionals. For 12 per cent of countries (9 out of 80), respondents did not know whether IYCF was integrated into the pre-service curriculum or not.

10%

PE

RC

EN

T O

F C

OU

NT

RIE

S

20%

0%

40%

50%

30%

70%

80%

60%

90%

100%

GlobalEast Asia & Pacific

Eastern & Southern Africa

Latin America & Caribbean

Middle East & North Africa

South Asia West & Central Africa

45%41%

45%45%

28%

22%

30%

20%

63%63%

79%

46% 43%

34%33%

26%

Eastern Europe& Central Asia

National law/Regulation to give effect to the code & subsequent wHA resolutions exist

maternity Protection law/Regulation exists



Globally, in 78 per cent of countries (62 out of 80) IYCF counselling or support is provided on a routine basis through the health system by trained health workers during individual or group sessions. Eighteen per cent of countries (14 out of 80) – half of them in sub-Saharan Africa – reported that IYCF counselling or support was not routinely provided, and 5 per cent (4 out of 80) did not know.

The proportion of health facilities that have IYCF-trained health workers varies strongly from country to country. Only 58 out of 80 countries responded to this question, of which 33 per cent (19 out of 58) indicated that they have no information available on the number of primary health-care facilities that have health workers trained on IYCF.

Although the data do not provide information on the quality or content of the counselling, the fact that the majority of countries were unable to provide information on the kind of IYCF training health workers had received – and did not know whether the training had occurred over the past five years – indicates that, generally, limited attention is paid to the quality of IYCF counselling and support.

Of the countries that responded, 38 per cent (22 out of 58) have high coverage of health facilities with trained IYCF health workers, meaning that at least 75 per cent of the primary health-care facilities have health workers trained on IYCF. Of the 40 countries with available information on maternity or health facilities that have ever been BFHI certified, only 45 per cent of respondents (18 out of 40 countries) indicated that some facilities had been recertified over the past five years. figure 3.3 provides further details on the percentages of health facilities with health workers who have received IYCF training.

Although integration of IYCF in the health system is a key component of IYCF programmes, 39 per cent of countries (31 out of 80) scored ‘insufficient’ for this aggregated indicator, which consists of:

● regular IYCF counselling, support and promotion in the health system,● percentage of primary health-care facilities that provide individual IYCF counselling by trained health providers or group education sessions; and● the number of trained health workers and BFHI certifications.

Twenty-six per cent of countries (21 out of 80) scored ‘fair’ for this indicator, while 24 per cent (19 out of 80) were rated ‘good’ or ‘very good’, as shown in Table 3.3.

TA b l e 3 . 3

oveRvIew of coUNTRy ScoReS foR INTegRATIoN of Iycf INTo THe

HeAlTH SySTem


(n=80)

Insufficient 39% 31

Fair 26% 21

good 24% 19

Very good 11% 9



f I g U R e 3 . 3

PeRceNTAge of HeAlTH fAcIlITIeS wITH Iycf-TRAINeD HeAlTH woRkeRS by coUNTRy

75 - 100%

50 - 74%

25 - 49%

0 - 24%

No response or unavailable

Not targeted




Iycf AT commUNITy levelImplementation of community-level activities is another key component of IYCF programmes and is particularly important when the health system is weak. For the aggregated indicator on implementation of IYCF at the community level, 43 per cent of countries (34 out of 80) scored ‘good’ or ‘very good’, while 58 per cent (46 out of 80) scored ‘fair’ and ‘insufficient’, as shown in Table 3.4. The score is based on whether the country has implemented community-based IYCF counselling, the proportion of districts with community-based IYCF programmes, and training on IYCF for community workers and their supervision.

In 2013, 70 per cent of countries (55 of 80) provided community-based counselling, including 28 countries in Eastern and Southern Africa and West and Central Africa. Twenty-five per cent of countries (20 of 79) do not have IYCF counselling activities at the community level.

figure 3.4 illustrates the percentages of districts that have community-based IYCF, out of the total number of districts in the country. The CEE/CIS, Latin America and the Caribbean, and West and Central Africa regions stand out as having a number of countries with more than 75 per cent of districts covered for IYCF counselling and communication.

TA b l e 3 . 4

oveRvIew of coUNTRy ScoReS foR Iycf ImPlemeNTATIoN

IN commUNITIeS


(n=80)

Insufficient 29% 23

Fair 29% 23

good 30% 24

Very good 12% 10



f I g U R e 3 . 4

PeRceNTAge of DISTRIcTS wITH Iycf-TRAINeD HeAlTH woRkeRS, 2013, by coUNTRy

Several agencies, including UNICEF, have developed IYCF counselling materials tailored to the community level. In 2011, UNICEF developed a community IYCF counselling package that guides local adaptation, design, planning and implementation of community-based IYCF counselling and support services at scale. It also contains training tools for community workers, using an interactive and experiential adult learning approach, with knowledge and skills on IYCF practices, counselling skills improvement, problem solving, negotiation and communication skills, and effective use of counselling tools and job aids.

While not mandatory to use it, seventy-three percent of countries (58 out of 79) use the UNICEF package, of which 30 countries use some elements of the UNICEF package incorporated into other packages. Of the countries that use the package, 31 per cent (8 out of 58) use the full UNICEF package, while 13 per cent (10 out of 79) use an abbreviated version of the training. Eastern and Southern Africa is the region where the most countries use the full package, while most respondents from the Middle East and North Africa indicated that they do not use the UNICEF package at all for IYCF training. Table 3.5 provides further details on the use of the IYCF package.

75 - 100% of districts




No response or unavailable

Not targeted




TA b l e 3 . 5

USe AND ADAPTATIoN of commUNITy Iycf coUNSellINg PAckAge, by RegIoN

INDICATOR CEE/CIS East Asia Eastern & latin Middle South Asia West & global & Pacific Southern America & East & Central Africa Caribbean North Africa Africa

# of target countries 22 27 21 36 20 8 24 158

No response 10 17 9 25 13 2 3 79

Responded 12 10 12 11 7 6 21 79

Entire UNICEF package adapted, with full 5-day training, 0 1 1 0 0 0 3 5 plus supervision

module

Entire UNICEF package adapted, with full 5-day training, 1 2 7 0 0 1 2 13 without supervision module

UNICEF package used, but abbreviated training of 2–3 days, plus 1 3 2 1 0 0 1 8 supervision module

UNICEF package used, but abbreviated training

of 2–3 days, without 0 0 0 1 0 1 0 2

supervision module

Some elements of UNICEF package incorporated into 6 2 2 4 2 4 10 30 other packages

Package not used at all for training 2 2 0 3 5 0 4 16

Don’t know 2 0 0 2 0 0 1 5


unite for children

Supervision of community workers is also an important activity to ensure that counselling is conducted adequately. Fifty-six per cent of countries (44 out of 79) are conducting supervision of community workers. Frequency of supervision varies from as often as once a month in 23 per cent of countries (10 out of 44) to once a year in 9 per cent of countries (4 out of 44) – with the highest percentage of countries (32 per cent, or 14 out of 44) providing supervisory visits every three months. A significant point, however, is that among the respondents that conduct supervision, 29 per cent of countries (12 out of 44) did not know how frequently these visits took place.

commUNIcATIoN STRATegIeSIn 2013, 58 per cent of countries (45 out of 77) had a communication strategy for IYCF in place, either as a stand-alone communication strategy for IYCF or integrated into a broader communication strategy. This is an improvement compared to 2011 IYCF programme assessment, in which 30 of the 61 respondents reported that they had an IYCF communication strategy.21

21 United Nations Children’s Fund, Infant and Young Child Feeding Programming Status: Results of 2010–2011 assessment of key actions for comprehensive infant and young child feeding programmes in 65 countries, UNICEF, New York, April 2012, p. 26.


moNIToRINgMonitoring of IYCF practices is essential but it is not systematically done. Overall, there is room for improvement in the monitoring of IYCF indicators, as 34 per cent of countries (27 out of 80) scored ‘insufficient’ for the aggregated IYCF monitoring and evaluation score, which is based on:

● monitoring of IYCF indicators in the HMIS;● the number of indicators monitored in the HMIS;● routine monitoring of IYCF indicators at the community level;● and the number of indicators monitored at the community level.

The same number scored ‘fair’ while 33 per cent of countries (26 out of 80) scored ‘good’ or ‘very good’. Unfortunately, no information was collected on the type of indicators monitored. Sixty per cent of countries (48 out of 80) reported that they are monitoring some IYCF indicators as part of the national HMIS, with the number of indicators integrated in the system ranging from one to five. However, only 38 per cent of countries (30 out of 80) conduct routine monitoring of IYCF at the community level.

PRovISIoN of foRTIfIeD comPlemeNTARy fooD AND fooD SUPPlemeNTSCounselling on age-appropriate, safe and nutritious complementary food is an important component of IYCF programmes. Local foods can be used in different combinations to improve dietary diversity and quality. and 55 per cent of countries (44 out of 80) indicate that local marketing initiatives for complementary foods including local production of such foods exist.

In addition, 38 per cent of countries (23 out of 60) provide products other than MNP through health facilities or outreach. Fifty-two per cent of these countries (12 out of 23) provide fortified complementary food, while 48 per cent (11 out of 23) provide food supplements such as lipid-based nutrient supplements and ready-to-use supplementary foods to improve the quality and nutrient density of children’s diets.

Finally, 38 per cent of countries (30 out of 79) have social protection programmes with a child nutrition component, for which cash transfers are the most common strategy.

Iycf IN emeRgeNcIeSForty-six per cent of the NutriDash respondents (36 out of 79 countries) indicated that they had implemented some type of IYCF activity as part of a response to an acute or protracted emergency in 2013. Table 3.6 summarizes the type of activities that took place in those countries.



coNclUSIoNSIYCF remains one of the most important subsets of interventions to improve child nutrition. However, countries are still at a nascent stage in integrating IYCF into health-system and community-level activities, and into national health information systems.

In general, the enabling environment for IYCF is weak: although most countries completing the module reported having an IYCF policy in place, only about one third have laws that reflect the full provisions of the Code. While most countries have maternity protection legislation in place, the duration and amount of paid maternity leave, availability of breastfeeding rooms in the workplace and provision for breastfeeding breaks need greater attention.Other areas for improvement include the content and quality of IYCF curricula for training of health-care providers, information availability on the type and quality of IYCF counselling provided through health services, and the supervision of community workers providing community-based counselling.

On a more positive note, most countries use community IYCF counselling packages (UNICEF or other packages) to support programme implementation. Also, more countries report having an IYCF communication strategy, either as stand-alone strategy or implemented in a broader community strategy.

While almost two thirds of countries (48 out of 80) reported monitoring of IYCF indicators within their national systems, monitoring at the community level is less prevalent. Strengthening monitoring systems will be an important step towards informing and improving IYCF programming.

UNICEF is currently in the process of updating its Infant and Young Child Feeding Guide to further support this programming area, and this will be available in 2015.

TA b l e 3 . 6

PeRceNTAge of coUNTRIeS ImPlemeNTINg Iycf AcTIvITIeS IN AN emeRgeNcy coNTexT (n=79), by TyPe of AcTIvITy

IYCF ACTIVITY PERCENTAgE

IYCF counselling in health services 78%

IYCF communication 61%

Mother support groups 50%

IYCF counselling/promotion by community workers 44%

Release of joint statement 25%

IYCF in rapid assessment 25%

Dealing with formula donations 22%

Monitoring of formula donations 11%

Distribution of formula for infants who have no possibility of being breastfed 6%



lalitpur – home to about 1 million people who live in 696 villages – is one of the most socially disadvantaged districts of Uttar Pradesh. learning from global evidence, the district of lalitpur launched the Baby-Friendly Community Health Initiative in 2006 to promote optimal breastfeeding practices through mother support groups.

The core strategy of the initiative was designed through a consultative process with the local stakeholders and relied on the formation of a breastfeeding mother support group for every 100 households. Along with an anganwadi worker and an accredited social health activist, every support group included a third person, either the anganwadi helper, a traditional birth attendant or a socially respected village woman. A total of 48 counsellors were recruited to form, train and monitor the 1,286 mother support groups that were established. In addition, a coordination team comprising the project director, the project coordinator and eight block monitors was formed to oversee implementation of the programme.

Counsellors participated in training on how to use the ‘Three-in-One Counselling Course on Infant and Young Child Feeding’. In turn, the counsellors trained the support groups through a three-day simplified training. After the training, each ‘mother support’ member identified 30–40 households as her cluster. Within this cluster, she identified all pregnant women and breastfeeding mothers with a child under 2 years old and visited them following an agreed-upon schedule: one visit in the first trimester of pregnancy, two visits in the third trimester of pregnancy, two visits in first seven days after delivery, and at least one monthly visit thereafter for six months. The support groups were equipped with visual communication tools to facilitate the counselling sessions.

Along with home visits, the support groups conducted theme-focused group counselling meetings with eligible families every Saturday. Some of the approaches adopted to make these meetings enjoyable included singing health-related folk songs, cooking nutritious foods for pregnant women and infants, demonstrating correct breastfeeding positioning and attachment, and celebrating traditional ceremonies. Finally, the groups used immunization days and growth monitoring sessions to reinforce messages on optimal infant and young child feeding. The members of the support group referred mothers with severe breastfeeding difficulties or severely undernourished children to the nearest block or district health facility for specialized advice and support.

Mother support groups were supervised monthly by their respective counsellors. Additionally, support groups attended

monthly review meetings facilitated jointly by block monitors and sector supervisors of the Integrated Child Development Services programme. Mother support groups did not receive any monetary incentive but were given travel compensation for training sessions and meetings, in-kind incentives such as bags, badges and counselling kits, and – most importantly – recognition in public events and media.

Assessments indicated that the four main factors that kept members of the mother support groups motivated were: good-quality training, mentoring and supportive supervision, good coordination among the group members, and social recognition.

In 2009, mother support groups were rated as ‘above average’ (A category), ‘average’ (B category) and ‘below average’ (C category) on

the basis of their performance. It was then decided that groups in the A category, which increased from 329 in 2009 to 764

in 2012, did not need to be visited by a counsellor any more. Thus, the number of counsellors was gradually

reduced from 48 to 10, and the number of block monitors from 8 to 4. The performance was rated using two criteria: (1) all members of the support group have demonstrated knowledge on optimal infant and young child feeding; and (2) infant and young child feeding practices in the area have improved.

In 2012, an external evaluation of the Initiative indicated that breastfeeding practices had

improved dramatically over the previous six-year period. For example: the proportion of children under

age 2 who were breastfed within one hour of birth had increased from 11 per cent to 82 per cent; the proportion of

those who were exclusively breastfed in the first three days of life (no prelacteal feeds, i.e., no food except mother’s milk was provided to a newborn before initiating breastfeeding) increased from 33 per cent to 97 per cent; finally, the proportion of infants 6–8 months old who were fed complementary foods while breastfeeding increased from 54 per cent to 83 per cent. Importantly, the attrition rate of group members over a period of six years was only about 10 per cent.

The experience in lalitpur confirms that mothers, if properly trained and supervised, can be successful breastfeeding counsellors in their communities and bring life-saving information and support closer to the mothers and families who need it most, when they most need it. Therefore, community-based mother support groups should be a key element of a comprehensive strategy to protect, promote and support optimal breastfeeding practices at scale, particularly in districts and blocks where front-line workers are scarce or overburdened.

baby Friendly Community initiative in Uttar pradeshby RIcHA SINgH AND Alok RANjAN

Good-quality training, mentoring and supportive

supervision, good coordination among the group members,

and social recognition

Iycf cASe STUDy


unite for children

Main pic: A breastfeeding counselor on home visits ensuring correct breast-feeding techniques in India. Twenty year old Babita Rajput is breast-feeding her 15 day old infant while receiving advice and information on exclusive breastfeeding.

Below: A mother feeding her one year old child. She has received care and information about improving her child’s nutrition in Beira Central Hospital, province of Sofala, Mozambique.

© UNICEF/INDA2010-00724/PirozziINDIA, 2010

© UNICEF/MOZA2006-01568/ giacomo Pirozzi


unite for children

AckNowleDgemeNTS


bAckgRoUND

Micronutrient powders (MNP) are sachets containing vitamins and minerals in a powdered form, which can be easily mixed into any semi-solid food that is ready for consumption. Given that a range of home-made foods can be fortified with MNP, their use is referred to as ‘home fortification’. MNP were developed to control iron deficiency anaemia, and numerous studies have proved such a benefit. As a result, WHO recommends the use of MNP to improve iron status and reduce anaemia among children aged 6–23 months.22

In recent years, the use of MNP has been widened to improve the quality of the diet in contexts where locally available foods do not provide enough essential nutrients.23 As a result, the recommended number of micronutrients contained in the powders has been increased from 3–5 micronutrients to a formula that includes at least 15 micronutrients.24

MNP programmes are also seeking to increase demand for services related to infant and young child nutrition, and thus spur overall improvements in IYCF programmes.

Children aged 6–23 months are a major population group that MNP interventions aim to reach, given that nutritional needs increase during this time period and insufficient intake may may irreversibly damage a child’s physical and mental development.25 MNP have also been used to fortify the meals of schoolchildren and other vulnerable groups, especially emergency-affected populations.

MNP programmes have rapidly expanded during the past five years and have been supported, for example, by five international, multi-agency workshops.26 A global assessment was conducted in 2011 to measure the progress achieved in MNP programmes,27 and the 2013 NutriDash module includes the data collection tools from this assessment in an abridged form.

22 World Health Organization, Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age, WHO, Geneva, 2011; available at: http://apps.who.int/iris/bitstream/10665/44651/1/9789241502047_eng.pdf.23 UNICEF and CDC, Global Assessment of Home Fortification Interventions 2011, Home Fortification Technical Advisory Group, Geneva, 2013, p. 1.24 Home Fortification Technical Advisory Group, ‘Programmatic Guidance Brief on the Use of Micronutrient Powders (MNP) for Home Fortification’, HF-TAG, December 2011, p. 2; available at: www.hftag.org/resource/hf-tag_program-brief-dec-2011-pdf.25 Victora, Cesar Gomes, ‘Worldwide Timing of Growth Faltering: Revisiting implications for interventions’, Pediatrics, vol. 125, no. 3, March 2010, pp. e473–e480.26 Timmer, Arnold, et al., ‘Home Fortification and Complementary Feeding: Regional workshops to scale up home fortification improve complementary feeding – Collaboration between UNICEF, CDC and partners’, in Home Fortification with Micronutrient Powders (MNP), Sight and Life, Basel, Switzerland, 2013, pp. 42–50.27 UNICEF and CDC, Global Assessment of Home Fortification interventions 2011, Home Fortification Technical Advisory Group, Geneva, 2013. 28 UNICEF and CDC, Global Assessment of Home Fortification Interventions 2011, Home Fortification Technical Advisory Group, Geneva, 2013, p. 14; and Jefferds, M. E., et al., ‘UNICEF-CDC Global Assessment of Home Fortification Interventions 2011: Current status, new directions, and implications for policy and programmatic guidance’, Food and Nutrition Bulletin, vol. 34, no. 4, December 2013, pp. 434–443. www.ncbi.nlm.nih.gov/pubmed/24605694

[ 4 ] Home foRTIfIcATIoN wITH mIcRoNUTRIeNT PowDeRS

fINDINgS

Sixty-four per cent of countries (101 out of 158) responded to the NutriDash MNP module in 2013, of which 58 countries indicated that they were not implementing any MNP interventions, and 43 were implementing MNP interventions – defined as interventions of any type and of any scale, excluding research.

In 12 countries, more than one intervention was ongoing, for example, when interventions were targeted to reach different populations. The 43 countries reported carrying out a total of 61 MNP interventions in 2013, representing a rapid increase compared to 2011, when just 22 countries implemented 34 MNP interventions.28 figure 4.1 provides a global overview of the implementation and planning for MNP .



F I g U R e 4 . 1

OveRvIew OF MNP PROgRAMMeS glObAlly IN 2013

Implementing MNP interventions

Planning MNP interventions

No interventions ongoing or planned

No data

Not targeted in survey




Table 4.1 shows the number of countries and the number of interventions, by region, in 2011 and 2013, highlighting East Asia and the Pacific, the Middle East and North Africa, and West and Central Africa as the regions with the largest increase during this time. An additional 21 countries have reported that they were planning MNP interventions in 2014.

In addition to the number of programmes implemented, there has also been a large increase in the number of programmes that reached national scale. In 2011, only 4 countries reported implementing MNP interventions at national scale. In 2013, 16 national-scale MNP programmes were carried out in 14 countries.

* Note: The 2011 Global Home Fortification Assessment targeted 152 countries.

Source: for 2011 data: UNICEF and CDC, Global Assessment of Home Fortification Interventions, 2011, Home Fortification Technical Advisory Group, Geneva, 2013, www.hftag.org/resource/global-assessment-of-home-fortification-interventions-2011-pdf.

INTegRATIoN of mNP INTeRveNTIoNSMNP interventions can be effectively linked to programmes in other sectors, including public health, education and social protection. Such integration was reported for 78 per cent of interventions (45 out of 59) in 2013. While 10 interventions maintain strong links with anaemia or micronutrient deficiency control programmes, 31 are housed within programmes for infant and young child nutrition, as shown in figure 4.2. It should be noted, however, that respondents could only choose one answer for this NutriDash question, so integration into multiple broader nutrition programmes might not have been captured.

f I g U R e 4 . 2

PeRceNTAge of mNP INTeRveNTIoNS (n=59) INTegRATeD INTo oTHeR bRoADeR PRogRAmmeS, 2013

TA b l e 4 . 1

oveRvIew of mNP INTeRveNTIoNS, 2011* (n=114) AND 2013 (n=101), by RegIoN

INDICATOR CEE/CIS East Asia Eastern & latin Middle South Asia West & global & Pacific Southern America & East & Central Africa Caribbean North Africa Africa

# of NutriDash target countries, 2013 22 27 21 36 20 8 24 158

# of countries implementing MNP 2 5 1 8 0 5 1 22 interventions, 2011

# of countries implementing MNP 3 10 4 9 5 5 7 43 interventions, 2013

# of MNP interventions implemented, 2011 2 6 1 14 0 10 1 34

# of MNP interventions implemented, 2013 3 16 8 12 7 8 7 61

Note: The 2011 Global Home Fortification Assessment targeted 152 countries.Source for 2011 data: UNICEF and CDC, Global Assessment of Home Fortification Interventions, 2011, Home Fortification Technical Advisory Group, Geneva, 2013, www.hftag.org/resource/global-assessment-of-home-fortification-interventions-2011-pdf.

Not integrated (n=13)

Anemia/micronutrient deficiency prevention & control (n=10)

Programmes to improve infant & young child nutrition (n=31)

School feeding programme (n=3)

Social Protection (n=1)

other (n=1)

22%

17%52%

5%2%2%



TARgeT Age gRoUPSIn line with the critical importance of the first two years after birth for a child’s life-long mental and physical development, 49 per cent of current global MNP interventions (30 out of 61) are targeted to reach children 6–23 months old. This age group is also covered in an additional 18 interventions that are aimed to reach children up to 35 months old (4 interventions), or up to 59 months (14 interventions), as shown in figure 4.3.

f I g U R e 4 . 3

NUmbeR of mNP INTeRveNTIoNS ImPlemeNTeD foR eAcH TARgeT Age gRoUP IN 2011 AND 2013

In 2013, MNP interventions for children aged 6–23 months reached an estimated 1.67 million children. In 2014, these interventions are aimed to reach an estimated 5.37 million children. A significant increase in reach is also expected for interventions that are targeted to reach children 6–59 months, from 590,000 in 2013 to 4.21 million in 2014. Given that the NutriDash 2013 data do not include the anticipated reach of the 21 countries planning to start implementation in 2014, further increases in the number of children reached may be possible. Data on whether or not participants completed the recommended regimen as per national recommendations were not available and are therefore not reflected in figure 4.4.

NU

MB

ER

OF

IN

TE

RV

EN

TIO

NS

0

5

10

20

25

15

30

35

6 - 35 months old

12 - 23 months old

6 - 59 months old

Pregnant & lactating women

School-agechildren

15

6 - 23 months old

Other

44

14

11

5 53

211

0 0

30 2011 (n=34 interventions)

2013 (n=61 interventions)



f I g U R e 4 . 4

NUmbeR of PARTIcIPANTS ReAcHeD IN 2013 AND exPecTeD To be ReAcHeD IN 2014 AmoNg ImPlemeNTeD INTeRveNTIoNS by TARgeT Age gRoUP

fINANcIAl AcceSS To mNPIn 2013, 86 per cent of interventions (51 out of 59) are public interventions giving MNPs free of charge, while the remaining 14 per cent are made up of the following combinations: three interventions are selling MNPs at a subsidized price, two interventions are giving MNPs for free to vulnerable groups while selling MNPs at a subsidized price to the rest and finally three interventions are giving MNPs for free to vulnerable groups while making MNPs generally available at full market price. All MNP interventions are equity-focused aiming to address malnutrition in the poorest or most vulnerable groups that are most at risk of suffering from malnutrition.

Overall, 42 per cent of respondents (21 out of 50 interventions) indicated poor monitoring systems as the top challenge faced by MNP interventions; these responses were consistent across five geographic regions. Thirty-two per cent of respondents (16 out 50) indicated that obtaining required funding for the MNP product was a challenge. Data collected on interventions from Latin America and the Caribbean, however, identified low human resources/capacity at the national or programme levels as the major challenge, while Eastern and Southern African countries identified an inadequate policy and legal framework as the primary challenge.

Currently, more than 3 million participants are being reached through MNP interventions, and it is projected that these same interventions will reach more than 12 million in 2014. These numbers illustrate that MNP programmes have experienced rapid scale-up in recent years – in fact, the number of countries implementing MNP interventions has doubled from 2011 to 2013. In East Asia and the Pacific alone, an additional 16 countries reported plans to implement MNP interventions in 2014.

With this rapid expansion, it is important that internal monitoring systems for home fortification interventions are developed and/or strengthened. This will enable assessment of the quality and coverage of MNP interventions, and support the necessary adjustments so that optimal nutritional benefits can be achieved for target groups. To this end, HF-TAG published a comprehensive manual on developing and implementing monitoring systems in 2013,29 and now houses a Community of Practice on Home Fortification30 to facilitate knowledge exchange and lessons learned.

29 Home Fortification Technical Advisory Group, ‘Manual for Developing and Implementing Monitoring Systems for Home Fortification Interventions’, HF TAG, Geneva, 2013.30 See: Home Fortification Technical Advisory Group, http://network.hftag.org.

coNclUSIoNS

IN M

ILL

ION

S

0

1

3

4

2

5

6

6 - 35 months old

12 - 23 months old

6 - 59 months old

Pregnant & lactating women

School-agechildren

6 - 23 months old

Other

8,0

00

8,0

00

1,6

73

,82

1

5,3

72

,66

2

63

9,3

21

1,2

43

,00

0

59

0,6

51

4,2

13

,15

4

41

9,9

73

73

7,7

01

27

7,6

03

34

1,7

83

30

,00

0

15

0,0

00

Reach in 2013 (n=45 interventions)

Planned reach in 2014 (n=45 interventions)



taking interventions from pilot to national scale in Kyrgyzstan

After launching an education component for IYCF in 2008, Kyrgyzstan initiated an MNP intervention in Talas Province in June 2009. The intervention is part of the broader IYCF programme to address the high rates of anaemia, which affects 50 per cent of the country’s children aged 6–35 months.31

MNP are being distributed through trained primary health-care providers (doctors, nurses and nurse practitioners) free of charge to all children 6–23 months old. Every two months, caregivers pick up a package of 30 one-gram sachets of MNP at their family health clinic. There, they are also given information on how to prepare and use the MNP properly and a reminder card with the date they should receive their next package.

As part of the internal monitoring system of the programme, the clinics keep patient registries that allow health-care providers to keep track of children who stopped using the powder, children who had side effects and those whose caretakers refused to try the MNP. The consumption schedule is flexible, as long as the child receives all 30 sachets within two months. Thus, a child consumes a total of 270 sachets within 18 months, starting at 6 months of age when the child begins complementary foods and ending at 24 months.

Kyrgyzstan procures its MNP through UNICEF, but in order to enhance acceptance the product was given the local brand-name ‘Gulazyk’, a Kyrgyz word that has historically referred to a dried meat product rich in nutrients and is eaten by warriors and travellers to give them strength and energy.32

The MNP intervention benefited from a strong media presence at the launch celebration, and mass-media support through publishing and broadcasting of advertisements, jingles and informational interviews. Additional communication activities were carried out at the community level by village health committee volunteers.

In 2008, before the start of the MNP intervention, a baseline survey had been conducted in Talas Province. A follow-up survey was conducted in 2010, one year after distribution of MNP. The surveys showed that, among all children 6–23 months of age, statistically significant declines were observed in the prevalence of anaemia, iron deficiency and iron deficiency anaemia, as follows: anaemia, 50.6 per cent versus 43.8 per cent (P=0.05); total iron deficiency (either low ferritin or high serum transferrin receptors), 77.3 per cent versus 63.7 per cent (P<0.01); and iron deficiency anaemia, 45.5 per cent versus 33.4

per cent (P<0.01).33

Based on the success of this pilot, embedded within a larger IYCF programme and coupled with

extensive health education and community mobilization, Kyrgyzstan scaled up its home fortification intervention maintaining the same approach in terms of target group, distribution channel and frequency, and consumption schedule. Currently, the intervention is implemented at national scale,

with the exception of the city of Bishkek).The rigorous monitoring and evaluation

system that was developed for the Talas Province pilot was extended to the national

programme. An internal monitoring system, based on administrative data, tracks the supply of MNP product, number of children who received MNP, number of children who refused, and the number and percentage of medical workers and village health committee volunteers who participated in training. These data are being complemented and triangulated by lot Quality Assurance Sampling,34 with two surveys conducted since the scale-up to measure the coverage, adherence and acceptability of the intervention.

The Kyrgyz nationwide MNP intervention is reaching more than 205,000 children 6–23 months of age, according to data collected through NutriDash.

by cHolPoN ImANAlIevA

For more information, please contact Ms. Cholpon Imanalieva at [email protected]

The Kyrgyz nationwide MNP

intervention is reaching more than 205,000

children 6–23 months of age

31 Research Institute of Obstetrics and Pediatrics (Kyrgyz Republic) and Marco International, Kyrgyz Republic Demographic and Health Survey 1997, Macro International, Calverton, Md., 1998, pp. 128, 132.32 Lundeen, Elizabeth, et al., ‘Integrating Micronutrient Powder into a Broader Child Health and Nutrition Program in Kyrgyzstan’, in Home Fortification with Micronutrient Pow-ders (MNP), Sight and Life, Basel, Switzerland, 2013, p. 24. 33 Serdula, M. K., et al., ‘Effects of a Large-Scale Micronutrient Powder and Young Child Feeding Education Program on the Micronutrient Status of Children 6–24 Months of Age in the Kyrgyz Republic’, European Journal of Clinical Nutrition, vol. 67, no. 7, July 2013, pp. 703–707. http://www.ncbi.nlm.nih.gov/pubmed/2353177934 Lundeen, Elizabeth, et al., ‘Integrating Micronutrient Powder into a Broader Child Health and Nutrition Program in Kyrgyzstan’, in Home Fortification with Micronutrient powder (MNP), Sight and Life , Basel, Switzerland, 2013, p. 26.

mNP cASe STUDy


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Chaya Rani adds micronutrient powders (MNP) to her 15 month old daughter’s food at their home in Sharisha Bari village, Jamalpur District, Bangladesh.

© UNICEF/BANA2012-02047/NooraniBANglADESH, 2012


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AckNowleDgemeNTS


bAckgRoUND

Iodine deficiency disorders (IDD) are the single most important preventable cause of brain damage in the world. IDD directly affect children’s learning capacities, women’s health, the quality of life of communities and economic productivity, and it is a problem in many industrialized countries as well as low-income settings. In nearly all countries, the most effective and sustainable strategy to reduce iodine deficiency is iodization of salt for household consumption, processed foods and livestock feed.

Recognizing the importance of preventing IDD, the 1990 World Summit for Children set the goal of eliminating iodine deficiency. Three years later, universal salt iodization (USI) – defined as iodization of all salt for human and animal consumption to the internationally agreed recommended levels – was endorsed as the main strategy to achieve this goal. Since then, intensive efforts have been made to implement SI programmes, and thus curb iodine deficiency.As of 2013, global consumption of adequately iodized salt reached 75 per cent,35 while the number of countries with documented iodine deficiency has decreased from 110 in 1993 to 32 in 2014.36 But despite the existence of long-standing SI programmes in numerous countries, and the related coverage gains, programme performance is likely to vary considerably between countries. The main aim of the NutriDash SI module is to examine key programme performance indicators; thus, it is complementary to global monitoring efforts tracking outcome indicators like ‘proportion of households consuming iodized salt’37 and ‘iodine status of the population’.38

35 United Nations Children’s Fund, ‘Table 2. Nutrition’, The State of the World’s Children 2015: Executive summary, UNICEF, New York, November 2014, p. 47; available at: www.unicef.org/publications/index_77928.html.36 ICCIDD Global Network, www.iccidd.org, accessed 22 October 2014.37 The ‘iodine status’ indicator is collected through major household surveys such as MICS and DHS, and subsequently collated by UNICEF. See: ‘Current + Progress’, www.data.unicef.org/index.php?section=topics&suptopicid=57.38 ICCIDD Global Network, ‘Global Iodine Scorecard for 2012’, available at: www.iccidd.org/p142000429.html. 39 Horton, Sue, Venkatesh Mannar and Annie Weslye, ‘Best Practice Paper: Food fortification with iron and iodine’, Working Paper, Copenhagen Consensus Center, Copenhagen, October 2008, p. 9; available at: www.copenhagenconsensus.com/sites/default/files/bpp_fortification.pdf.

[ 5 ] SAlT IoDIzATIoN

fINDINgS

For the SI module, NutriDash received responses from 86 countries. Given that not all questions apply to all countries, and not all respondents answered all questions, the denominator varies for each indicator. The main respondents for the module were UNICEF country offices, but in some cases, representatives from governments or other organizations provided the required data. One overall finding is that 48 per cent of countries (35 out of 73) started salt iodization programmes during the 1990s after the World Summit for Children, while 23 per cent of countries (17 out of 73) started iodizing salt before the 1990s, and 29 per cent (21 out of 73) started after 2000.

PolIcy eNvIRoNmeNTGlobal experiences show that, compared to voluntary iodization, legislation for mandatory salt iodization more reliably ensures that adequate amounts of iodine are supplied to households.39 Eighty-five per cent of countries (73 out of 86) have mandatory legislation in place, as shown in figure 5.1.



f I g U R e 5 . 2

PeRceNTAge of coUNTRIeS wITH mANDAToRy SAlT IoDIzATIoN (n=73), by SAlT commoDITIeS

coveReD UNDeR THe lAw

Given that an increasing amount of salt globally is consumed through processed foods, rather than being added at home during cooking, the iodization of all forms of salt destined for human (and animal) consumption is likely to best reach all relevant population segments. In 41 per cent of the countries with mandatory legislation (30 out of 73), the laws cover all three forms: table salt, salt for the production of one or more processed food items, and salt for livestock feed. Legislation in 3 per cent of countries (2 out of 73) only covers salt for processed foods and does not include table salt. Further details on the commodities covered in mandatory salt iodization laws are shown in figure 5.2.

f I g U R e 5 . 1

PeRceNTAge of coUNTRIeS (n = 86) wITH mANDAToRy SAlT IoDIzATIoN legISlATIoN, volUNTARy IoDIzATIoN

legISlATIoN, oR No legISlATIoN

No IoDIzATIoNlegISlATIoN

mANDAToRy IoDIzATIoN

86% 10%

4%voUNTARy IoDIzATIoN

% of coUNTRIeS

mANDAToRy IoDIzATIoN of TAble SAlT

97% 59%

51%

40%

% of coUNTRIeS

mANDAToRy IoDIzATIoN of oNe oR moRe PRoceSSeD fooD ITemS

mANDAToRy IoDIzATIoN of All THRee SAlT commoDITIeS

mANDAToRy IoDIzATIoN of lIveSTock feeD



NATIoNAl owNeRSHIP AND PRogRAmme goveRNANceAs part of efforts to address iodine deficiency in a sustainable way, commitments to eliminate iodine deficiency are part of national policies in 75 per cent of the countries (64 out of 85) that responded to NutriDash. However, these elimination efforts are also integrated into annual government plans and budgets in only 35 per cent of countries (30 out of 85).

Seventy-five per cent of countries (63 out of 84) have an ‘Iodine Deficiency Disorders Elimination (IDDE)’ coordination body that includes the public sector, of which in 14 per cent (12 out of 84) the coordination body consists of the public sector only and in 61 per cent of countries (51 out of 84) it includes both the public and private sector (i.e.,industry).

PRocURemeNT of PoTASSIUm IoDATePotassium iodate (KIO3) is the most common chemical component used to iodize salt in low- and middle-income settings. Therefore, adequate KIO3 procurement and supply systems are essential for salt iodization programmes.

Ensuring KIO3 procurement needs without external donor assistance is an indicator of sustainability. However, only 42 per cent of countries (28 out of 66) confirmed that sufficient amounts of KIO3 were procured without external funding to cover production needs of iodized salt in 2013. Of those 28 countries, 17 reported that the cost of KIO3 procurement was absorbed by industry, 9 reported that it was funded by government, and 2 indicated that the funding for KIO3 came from both government and industry.

moNIToRINg AND evAlUATIoN AND QUAlITy ASSURANceAs shown in Table 5.1, 53 per cent of countries (43 out of 81) have national regulations that specify mandatory SI and foresee enforcement of these regulations at the production level, the import level and the commercial level. Twelve per cent of countries (10 out of 81), on the other hand, indicated that they have no regulations in place.

TA b l e 5 . 1

PeRceNTAge of coUNTRIeS (n = 43), by level of eNfoRcemeNT of RegUlATIoNS

foR mANDAToRy SAlT IoDIzATIoN

level of enforcement % of countries

Production, commercial and import 53%

Production and commercial 9%

Production and import 4%

Commercial only 2%

Production only 5%

Import only 6%

No regulations 12%



Regarding the context, it is important to note that 21 per cent of countries (18 out of 84) produce all their salt in-country, 25 per cent (21 out of 84) import all their salt from abroad, and 54 per cent (45 out of 84) both produce and import.

External and internal quality assurance (QA) and quality control (QC) are essential in ensuring that the iodization of salt complies with national standards.

External QC refers to activities such as inspections mandated by the national regulatory body and carried out by food control agencies to guarantee food safety and compliance with national standards. These activities are an intrinsic part of the enforcement process as laid out by the regulations for iodized salt, and can take place at the production, import and/or retail levels, depending on the country context.

External quality control generally includes the inspection of records related to internal QA/QC procedures and the analysis of salt samples. Eighty-seven per cent of countries (71 out of 82) have established clear rules and operating procedures for external QC. However, only 11 per cent of countries (9 out of 81) indicated that these rules and operating procedures were widely applied by food control and other responsible national authorities in 2013.

Internal QA/QC takes place at the level of salt production, and consists of specific activities that producers need to regularly carry out and document in order to guarantee that their product is of high quality and complies with national standards. This includes both the manufacturing process and monitoring of the final salt product. Although 70 per cent of countries (45 out of 64) have standards and responsibilities for internal QA/QC clearly established, only 25 per cent (15 out of 64) also indicated that salt producers widely complied with these standards and responsibilities in 2013.Twenty-one per cent of countries (17 out of 82) have clear rules and operating procedures for external QC covering production/import and commercial levels, as well as clear standards and responsibilities for internal QA/QC. Thirty-nine per cent of countries (32 out of 82) indicated that they have clear rules and operating procedures for external QC established at both levels – production/import40 and commercial – which were widely applied by food control and other responsible national authorities in 2013, as well as clearly established standards and responsibilities for internal QA/QC, which salt producers widely complied.

In 10 per cent of countries (8 out of 82 countries), rewards were offered to well-performing salt producers in 2013, while punitive actions were implemented in 22 per cent for producers violating the national salt legislation. Seventy-four per cent of respondents (61 out of 82 countries) indicated that the SI programme in their country has never been externally evaluated. However, 16 per cent (13 out of 82 countries) have plans for an independent external evaluation of their SI programme during the next two years.

commUNIcATIoNWhile previous communication initiatives to establish SI programmes targeted governments to secure policy commitments, industry to alter production and business practices, and consumers to accept and demand iodized salt, current advocacy may require a more targeted and strategic approach.

A communication strategy for iodized salt addressing barriers along the value chain from production/import to consumption is in place in 28 per cent of countries (27 out of 82). In 33 per cent of countries (26 out of 82) communication activities are being implemented without a guiding strategy, while 39 per cent (32 out of 82) do not conduct any communication activities related to salt iodization.

40 Import and production level were combined as answer options in the questionnaire, as some countries do not import and others do not produce. The question was aimed to see which countries monitored only at commercial level, and which did not monitor at commercial level.



In other findings, respondents from 79 per cent of countries (66 out of 84) indicated that more than half of salt is clearly recognizable as iodized at the point of sale. Furthermore, IDD and USI are integrated into:

● training for community health workers in 60 per cent of countries (49 out of 81) ● continued medical education for nurses, doctors and nutritionists in 53 per cent of countries (43 out of 81) ● the general school curriculum in 30 per cent of countries (24 out of 81) - food technology training programmes in 27 per cent of countries (22 out of 81) ● the pre-service training of relevant public employees such as from the health or industry/ commerce sectors in 26 per cent of countries (21 out of 81).

PRogRAmme PeRfoRmANce ScoReFor 2013, 86 countries provided data on the SI programme.

In order to generate a single performance score for national SI programmes, data from four programme areas – policy environment; national ownership and programme governance; communication; and monitoring and evaluation and QA/QC – were consolidated. At the high end of the programme performance results, 26 per cent of countries (22 out of 86) had a score between 75 and 100, and at the low end, 14 per cent of countries (12 out of 86) had a score between 0 and 24.

In the score calculation, 10 per cent weight was given to communication, while the other three components were each given 30 per cent weight. Within each area, questions were assigned specific weights. Of note, the score does not consider the proportion of households consuming iodized salt or the iodine status of the population, as it exclusively focuses on programmatic components.

Two calculators for the score – one for countries that produce salt and the other for countries with no salt production – can be found in Annex Iv. The scoring mechanism will be further refined in the future.

coNclUSIoNS AND wAy foRwARDSalt iodization is a mature programme that has been implemented in many countries for several years and is considered to be a public health success story. However, information collected through NutriDash shows that there are a number of programmatic barriers – including KIO3 procurement systems, monitoring and QA/QC, and communication – that prevent programmes from achieving better results and reaching more people with adequately iodized salt. In order to improve quality coverage and move towards more sustainable programmes, governments and industry, in partnership with key stakeholders, must increase efforts towards overcoming barriers and strengthening programme components.


(n=86)

Insufficient 14% 12

Fair 27% 23

good 34% 29

Very good 26% 22

TA b l e 5 . 2

oveRvIew of coUNTRy ScoReS oN USI PRogRAmme PeRfoRmANce



ethiopia’s history of commitment to eliminate iDD

The people of Ethiopia have suffered from severe iodine deficiency for a long time. Salt iodization was introduced during the 1980s, and good coverage with iodized salt was achieved. However, with the secession of Eritrea and a shift to importation of non-iodized salt from Djibouti, the coverage of iodized salt returned to very low levels. In 2011, Ethiopia had the lowest coverage of adequately iodized salt in sub-Saharan Africa: Only 15 per cent of households had access to adequately iodized salt (DHS 2011). As a result, goitre rates remained extremely high, and the urinary iodine concentration was very low, at 24.5 micrograms per litre among school-aged children.

Ethiopia’s recent story is one of impressive progress due to strong government commitment and ownership. In 2011, the Council of Ministers passed new salt legislation, and the Government – led by the Ministry of Health – started enforcing this legislation, with support from international partners including GAIN, the Micronutrient Initiative and UNICEF. National salt production was developed in Afar Region, where iodization efforts were focused. A national coordinating committee, including all relevant ministries, was set up, and a USI technical steering committee was formed to lead such initiatives as drafting the joint USI national plan, resource mobilization, and communication and advocacy.

As a priority, efforts focused on setting up iodization capacity in the salt-producing sector with provision of iodization machinery, training and in-kind donations of KIO3. Gradually, a cost recovery scheme for sustainable supply of KIO3 – based on funds collected from the salt producers – was set up and is fully functioning, independently from external support. Targeted communication also focused on producers, distributors and salespeople along the supply chain.

In less than two years of dedicated commitment to the elimination of IDD, great results have been achieved: The majority of salt in Ethiopia is exposed to iodization, and 95 per cent of salt consumed in households contains iodine. The iodization method, however, is poor, and modernization towards industrial iodization of salt is the next phase planned for the USI programme. To improve quality, salt producers, the Government of Ethiopia, private investors and partners will further support

investment in infrastructure, machinery and capacity-building to shift iodization practices

away from manual iodization towards more robust methods.

The Government is also working with partners to strengthen internal and external QA/QC. A key activity in this regard is capacity-building for the enforcement and monitoring agency – the Ethiopian Food, Medicine and

Healthcare Administration and Control Authority – including the establishment

of a detailed and budgeted plan for QA/QC activities. Additionally, a new national guideline

on QA/QC for salt iodization has been developed and rolled out for application by the Administration and Control Authority among salt producers.

In order to monitor the nutrition situation in Ethiopia, the Government is carrying out a national micronutrient survey in 2014, with support from partners. The survey will include a specific iodine module to assess urinary iodine levels among school-aged children and women, as well as household availability of iodized salt for which salt samples will be collected from all households and subjected to titration analysis. The survey will quantify the progress that Ethiopia has made towards eliminating IDD, and its results will inform efforts future efforts to improve the quality and sustainability of salt iodization.

by TeSfAye cHUko

Ethiopia’s recent story is one of impressive

progress due to strong government

commitment and ownership

For more information, please contact Mr. Tesfaye Chuko at [email protected]

SI cASe STUDy


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AckNowleDgemeNTS


THe cRUcIAl Role of NUTRITIoN INfoRmATIoN SySTemS

The development of NutriDash is an innovative step towards systematically harmonizing and collecting programme data on key nutrition-specific interventions globally. Complementing other sources of nutrition data, NutriDash fills a gap in understanding the coverage and performance of programmes in the varied contexts where UNICEF works. Because translating political, financial and policy commitments to nutrition and improving programme implementation requires timely, comprehensive and relevant information, this is a valuable contribution. In fact, the global momentum for scaling up nutrition cannot be realized without investments in nutrition information systems to support programme implementation and monitor progress.

As this report highlights, it is evident that nutrition interventions are being expanded within and across countries. Millions of children and their families and communities are benefiting from nutrition services, and this is a welcomed trend. Challenges, of course, remain and more must be done to create an enabling environment whereby govern-ments are increasingly supported to take ownership and dedicate resources to nutrition programming. Such efforts are being supported through the work of the SUN Movement and other nutrition champions.

[ 6 ] coNclUSIoNS AND wAy foRwARD

SUPPoRTINg UNIcef gUIDANce

UNICEF’s new guidance on scaling up nutrition programming work is currently being rolled out across the organization. A key operational approach of this guidance relates to strengthening systems to ensure effective monitoring, evaluation and knowledge management to improve nutrition policy and programming. This approach necessitates strengthening national, sub-national and community-based monitoring and evaluation processes and ensuring that the knowledge acquired is used to promote institutional learning to improve programme performance.

NutriDash is one means to operationalize this guidance. By providing direction on key programme indicators to collect, as well as through systematic capacity-building and collaboration to improve national systems, NutriDash can play a vital role in supporting nutrition information systems.

Moreover, as NutriDash highlights, information systems are crucial for informing the nutrition situation analysis, designing and planning programmes, and monitoring and evaluation. For UNICEF in particular, NutriDash can have an important role in programme planning and supply forecasting, ensuring that the necessary inputs are procured to best meet the needs of the populations that nutrition programmes aim to reach.

APPlyINg leSSoNS leARNeD fRom THe NUTRIDASH PIloT

Many lessons have been learned during this 2013 pilot experience, which are being used to inform and refine the NutriDash process. Based on users’ feedback, the questionnaires are being improved and streamlined, with further rationalization of indicators. Changes are also being made to the data checking and quality processes. The user interface is being modified and improved, including providing information in easy-to-use formats to efficiently inform decision making. Finally, the internal planning function of NutriDash will be enhanced to directly link to supply forecasting.

The second round of data collection through NutriDash has been scheduled to start at the beginning of 2015. While the 2013 data collection created a baseline for many indicators, the update will allow tracking progress in many areas and will show geographical trends.

NutriDash represents a major collective effort to strengthen data collection and quality for nutrition programming. This ongoing collaboration seeks to strengthen systems for effective nutrition programming, supporting our joint efforts to deliver results and ultimately improve maternal and child nutrition.


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Children play at a salt production site that is supported by UNICEF and pose with a bag that will be used to transport and sell the iodized salt on the island of Pemba, Tanzania.

© UNICEF/UNI161967 and UNI161968/HoltTANZANIA, 2014


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ANNex I

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coUNTRy ReSPoNDeNTS To NUTRIDASH

coUNTRIeS, by RegIoN, THAT ReSPoNDeD To eAcH moDUle of THe NUTRIDASH SURvey

Region and countries SAM IYCF MNP SI # of responses


CEE/CIS

Albania 3

Bosnia and Herzegovina 4

Kazakhstan 4

Kosovo 2

Kyrgyzstan 3

Moldova 2

Tajikistan 4

The former Yugoslav Republic of Macedonia 3

Turkmenistan 3

Ukraine 3

Uzbekistan 4

EAST ASIA AND PACIFIC

Cambodia 4

China 3

Cook Islands 1

Democratic People’s Republic of Korea 3

Fiji 1

Indonesia 4

Kiribati 1

lao People’s Democratic Republic 3

Malaysia 1

Marshall Islands 1

Micronesia (Federated States of) 1

Mongolia 4

Myanmar 4

Nauru 1

Niue 1

Palau 1

Papua New guinea 4

EAST ASIA AND PACIFIC (CoNt.)

Philippines 4

Samoa 1

Solomon islands 1

Thailand 1

Timor-leste 4

Tokelau 1

Tonga 1

Tuvalu 1

Vanuatu 1

Viet Nam 4

EASTERN AND SOUTHERN AFRICA

Angola 4

Botswana 3

Burundi 4

Eritrea 4

Ethiopia 4

Kenya 4

lesotho 1

Madagascar 3

Malawi 4

Mozambique 4

Namibia 4

Rwanda 4

Somalia 4

South Sudan 1

United Republic of Tanzania 3

Zambia 3

Zimbabwe 4

ReSPoNSe No ReSPoNSe





lATIN AMERICA AND CARIBBEAN

Bolivia (Plurinational State of) 4

Brazil 1

Colombia 4

Cuba 4

Dominican Republic 1

Ecuador 2

El Salvador 4

guatemala 3

guyana 4

Haiti 4

Mexico 3

Nicaragua 4

Panama 4

Peru 1

Suriname 4

Uruguay 1

MIDDlE EAST AND NORTH AFRICA

Algeria 4

Djibouti 4

Egypt 2

Iraq 4

Morocco 3

Oman 1

Sudan 4

Syrian Arab Republic 4

Yemen 4

SOUTH ASIA

Afghanistan 4

Bangladesh 4

SOUTH ASIA (CoNt.)

Bhutan 1

India 3

Maldives 1

Nepal 4

Pakistan 4

Sri lanka 4

WEST AND CENTRAl AFRICA

Benin 4

Burkina Faso 4

Cameroon 4

Central African Republic 4

Chad 4

Côte d’Ivoire 3

Democratic Republic of the Congo 4

Equatorial guinea 4

gabon 2

gambia 4

ghana 4

guinea 4

guinea-Bissau 4

liberia 4

Mali 4

Mauritania 4

Niger 4

Nigeria 3

Sao Tome and Principe 3

Senegal 2

Sierra leone 4

Togo 4

ReSPoNSe No ReSPoNSe


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ANNex II

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Iycf ScoRe cAlcUlAToR

Question Score Question Score

ENABlINg ENVIRONMENT

Does your country have a stand-alone Yes 1

national Iycf policy or strategy? no 0

If there is no stand-alone policy:

no policy/strategy at all 0

iYCF elements are integrated within nutrition policy/strategy 0.5

iYCF elements are integrated within the child health policy/strategy 0.25

other 0.1

Is Iycf counselling and support included in

pre-service curricula for health professionals?

Yes – comprehensively for medical doctors 1

Yes – comprehensively for nurses/other health professionals 1

Minimally for medical doctors 0.5

Minimally for nurses/other health professionals 0.5

no 1

Are there national laws and/or regulations to give effect to the

International code of marketing of breast-milk Substitutes and

subsequent world Health Assembly resolutions?

Yes – all 1

Yes – partially, with some provisions/laws or voluntary 0.5

no – but laws are drafted/in progress 0.25

no laws or actions 0

Responsibility for monitoring and enforcing Yes 1

the national legislation based on the code? no 0

If yes, with what periodicity did this agency/body

undertake monitoring and enforcement activities?

each quarter 1

2–3 times 1

annually 0

not in the past year 0

Is supervision usually carried out? Yes 1

no 0

HEAlTH SYSTEM

Is regular Iycf counselling/support/promotion Yes 1

currently implemented in the health system? no 0

Percentage of primary health-care facilities

providing individual Iycf counselling by a

trained health provider 1 point for every 33%

HEAlTH SYSTEM (CoNt.)

Percentage of primary health-care

facilities providing Iycf group

education/communication sessions 1 point for every 33%

Training for health-care workers 1 point if training is taking place

Status of bfHI certification

number of facilities classified as baby-Friendly 1 point for 1 or more facilities

number of facilities classified as such

during the past 5 years 1 point for 1 or more facilities

COMMUNITY

Is community-based Iycf counselling

and/or promotion/communication Yes 1

currently implemented? no 0

Percentage of districts in the country

implementing community-based

programmes that include Iycf 1 point for every 33%

Has any training on Iycf for community Yes 1

works taken place in the past 3 years? no 0

Is training for community workers Yes 1

currently taking place? no 0

Is there supportive supervision Yes 1

of community workers? no 0

How often is supervision usually each month 2

carried out? every 3 months 2

every 6 months 2

annually 1

MONITORINg AND EVAlUATION

Are any Iycf indicators Yes 1

monitored in the HmIS? no 0

How many indicators are 1 1

monitored in the HmIS? 2 or more 2

Is there routine monitoring of Iycf Yes 1

indicators at the community level? no 0

How many indicators are monitored 1 1

at the community level? 2 or more 2



ANNex III

mNP INTeRveNTIoNS by RegIoN, coUNTRy, PRoDUcT AND TARgeT Age gRoUP

6-23 12-23 6-35 6-59 Pregnant & School-aged Other months months months months lactating children target women group

ce

ec

ISe

AP

Re

SA

Rl

Ac

Rm

eN

AR

oS

Aw

cA

R

15 m

icro

nutr

ient

MN

P

5 m

icro

nutr

ient

MN

P

Oth

er

pro

duct

5 m

icro

nutr

ient

MN

P

15 m

icro

nutr

ient

MN

P

5 m

icro

nutr

ient

MN

P

Oth

er

pro

duct

15 m

icro

nutr

ient

MN

P

5 m

icro

nutr

ient

MN

P

Pro

duct

not

sp

ecifi

ed

15 m

icro

nutr

ient

MN

P

MN

P p

roduct

for

school-aged

Oth

er

pro

duct

15 m

icro

nutr

ient

MN

P

Tota

l

Countr

ies

Regio

ns

kyrgyzstan 1 1

Tajikistan 1 1

Uzbekistan 1 1

cambodia 1 1

china 1 1

Indonesia 1 1 2

korea 1 1 2

lao 1 1 2

mongolia 1 1 2

myanmar 1 1

Philippines 1 1

Timor-leste 1 1

vietnam 2 1 3

kenya 1 1

madagascar 1 1 2

mozambique 4 4

Rwanda 1 1

bolivia 1 1

colombia 1 2 1 4

Dominican Republic 1 1

ecuador 1 1

guatemala 1 1

guyana 1 1

Haiti 1 1

Nicaragua 1 1

Peru 1 1

Djibouti 2 2

egypt 1 1

Sudan 1 1

Syrian Arab Republic 1 1

yemen 1 1 2

Afghanistan 1 1

bangladesh 1 1 1 3

Nepal 1 1

Pakistan 1 1 2

Sri lanka 1 1

cameroon 1 1

chad 1 1

Democratic

Republic of congo 1 1

ghana 1 1

mali 1 1

Nigeria 1 1

Sao Tome & Principe 1 1

ToTAl 24 5 1 1 1 2 1 12 1 1 5 4 1 2 61


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ANNex Iv

USI PRogRAmme PeRfoRmANce ScoRe cAlcUlAToR

Annex Iv contains two tables: one for calculating the USI programme performance score in countries that produce salt internally, and the other for calculating the USI programme performance score in countries that do not produce their own salt.

MAIN CATEgORIES WEIgHT

Policy environment 30%

National ownership and programme governance 30%

Communication 10%

Monitoring and evaluation and QA/QC 30%

USI PRogRAmme PeRfoRmANce – cAlcUlATIoN foR coUNTRIeS wITH IN-coUNTRy SAlT PRoDUcTIoN

TA b l e I I I a

Category Score Weight Category Score Weight

POlICY ENVIRONMENT 30%

for which of the following is iodization mandatory under the law? 30%

0 iodization is voluntary only 0 no legislation 0.1 iodization of salt for livestock feed 0.4 iodization of salt for one or more processed foods 0.5 iodization of table salt 0.9 iodization of table salt and salt for processed foods 1 iodization of table salt, salt for processed foods and livestock feed

Are government regulations/standards for the implementation (enforcement) of the law fully in line with the law? 30%

1 Yes – regulations are fully in line with the law 0.5 Regulations are partially in line with the law 0 no regulations exist

Is the elimination of IDD through USI integrated into the following: 15%

1 a. national policies and strategies + b. national annual plans and budgets + c. Government’s policy reviews and/or programme reviews 0.6 a + b oR a + c 0.8 b + c 0.2 a. national policies and strategies 0.4 b. national annual plans and budgets 0.4 c. Government’s policy reviews and/or programme reviews 1 d. not integrated – it is a costed stand-alone national plan/ strategy that is regularly reviewed by the government 0.4 e. not integrated – it is a costed stand-alone plan/strategy that is not included in government reviews 0 f. not integrated – it is a stand-alone plan with no budget

Are there national food standards for packaging and labelling that include iodized salt? 25%

1 Yes 0 no

NATIONAl OWNERSHIP & PROgRAMME gOVERNANCE 30%

Is IDD elimination a funded line item in the national budget? 20%

1 yes 0 no

was kIo3 procurement (to fulfil domestic needs) maintained without external funding in the past calendar year? 35%

0.5 only partially maintained – through government or industry or both 1 Yes – through government and industry funds jointly 1 Yes – through government subsidies 1 Yes – through industry funds 0 no

Does a national coordination body exist that coordinates IDD elimination and that includes both public and private sectors?

15%

0 no – it does not exist 0.5 Yes – it includes only the private sector 0.5 Yes – it includes only the public sector 1 Yes – it includes both the public and private sectors

was the coordination body functioning effectively in the past calendar year as defined by annual workplan, roles and responsibilities and regular meetings?

15%

0.3 b. Yes – it was meeting 2 or more times 0 d. no – it was not functioning effectively 0.3 c. Yes – it had defined roles and responsibilities 0.4 a. Yes – it had an annual work plan 1 a + b + c 0.7 a + b 0.7 a + c 0.6 b + c

what percentage of domestic salt supply comes from medium- and large-scale producers?

15%

0 Don’t know 0.6 between 40% and 70% 0.2 less than 40% 1 70% or more

Category Score Weight

COMMUNICATION 10%

Is iodized salt clearly recognizable as iodized to the consumer (e.g., label/logo/poster in shop/kiosk)?

30%

1 Yes – more than 50% of iodized salt is recognizable 0 no – less than 50% of iodized salt is recognizable

Is a communication strategy in place that addresses identified bottlenecks from production/import of iodized salt to reaching the population?

35%

0 no 0.3 no – but some communication activities take place 1 Yes

Is education about IDD and iodized salt included as part of any of the following items?

35%

0 f. none 0.2 e. Continuous medical education for nurses, doctors and nutritionists 0.2 d. training for community health workers 0.2 c. pre-service training for public employees (health and/or industry/commerce) 0.2 b. Food-technology training programme 0.2 a. School curriculum 1 all 5 – a + b + c + d + e 0.8 any combination of 4 0.6 any combination of 3 0.4 any combination of 2


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MONITORINg AND EVAlUATION AND QUAlITY ASSURANCE (QA)/QUAlITY CONTROl (QC)

30%

Does a national monitoring system exist that tracks programme activities (e.g., policy implementation, production,

supply, communication)?

10%

0 no 1 Yes

Are any monitoring data reported and used for corrective action/programme adjustments?

10%

1 Yes 0 no

Are rules and operating procedures for external Qc (inspections and sample taking at the production/import and the

commercial levels) by national authorities clearly established?

10%

1 Yes – for both production/import and commercial 0.3 Yes – for the commercial level only 0.7 Yes – for the production/import level only 0 no – rules & operating procedures are not clearly established

Have the rules and procedures for external Qc been applied by national authorities in the past calendar year?

10%

0 no – they were not applied 0.5 Yes – they were partially applied 1 Yes – they were widely applied

Are standards and responsibilities for internal QA at the production level clearly established?

20%

0 no 1 Yes

Have iodized salt production sites complied with the standards for internal QA in the past calendar year? 20%

0 no 0.5 Yes – they have partially complied 1 Yes – they have widely complied

In the past calendar year, were there any examples of punitive or rewarding actions (including public recognition) relating to the compliance of salt producers with QA standards for iodized salt?

10%

0 no – there were neither punitive nor rewarding actions 1 Yes – there were rewarding actions (recognition) 1 Yes – there were punitive actions

Has the salt iodization programme in your country been evaluated by external independent evaluators in the past 5 years?

10%

0 no 1 Yes 1 no – but there are plans for an evaluation in the next 2 years


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USI PRogRAmme PeRfoRmANce – cAlcUlATIoN foR coUNTRIeS wITH No IN-coUNTRy SAlT PRoDUcTIoN

TA b l e I I I b

Category Score Weight Category Score Weight

POlICY ENVIRONMENT 30%

for which of the following is iodization mandatory under the law? 30%

1 iodization of table salt and salt for processed foods and livestock feed 0.9 iodization of table salt and salt for processed foods 0.5 iodization of table salt only 0.4 iodization of salt for one or more processed foods only 0.1 iodization of salt for livestock feed only 0 legislation exists but iodization is voluntary only 0 no legislation

Are government regulations/standards for the implementation /enactment of the law fully in line with the law? 30%

1 Yes 0.5 partially 0 no

Is the elimination of IDD through USI integrated into the following: 15%

1 a. national policies and strategies + b. national annual plans and budgets + c. Government’s policy reviews and/or programme reviews 0.6 a + b oR a + c 0.8 b + c 0.2 a. national policies and strategies 0.4 b. national annual plans and budgets 0.4 c. Government’s policy reviews and/or programme reviews 1 d. not integrated – it is a costed stand-alone national plan/ strategy that is regularly reviewed by the government 0.4 e. not integrated – it is a costed stand-alone plan/strategy that is not included in government reviews 0 f. not integrated – it is a stand-alone plan with no budget

Are there national food standards for packaging and labelling that include iodized salt? 25%

1 Yes 0 no

NATIONAl OWNERSHIP & PROgRAMME gOVERNANCE 30%

Is IDD elimination a funded line item in the national budget? 30%

1 yes 0 no

Does a national coordination body exist that coordinates IDD elimination and that includes both public and private sectors? 35%

1 yes it includes both 0.5 yes, only public sector 0.5 yes, only private sector 0 no it does not exist

was the coordination body functioning effectively in the past calendar year: annual work plan, defined roles and responsibilities, regular meetings (at least 2 meetings)? 35%

1 a. annual work plan + b. Defined roles and responsibilities + c. Meeting 2 or more times 0.7 a + b oR a + c 0.6 b + c 0.4 a. annual work plan 0.3 b. Defined roles and responsibilities 0.3 c. Meeting 2 or more times 0 d. no – it was not functioning effectively


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COMMUNICATION 10%

Is iodized salt clearly recognizable as iodized to the consumer (e.g., label/logo/poster in shop/kiosk)?

30%

1 Yes – more than 50% of iodized salt is recognizable 0 no – less than 50% of iodized salt is recognizable

Is a communication strategy in place that addresses identified bottlenecks from production/import of iodized salt to reaching the population?

35%

1 Yes 0.3 no – but some communication activities take place nonetheless 0 no

Is education about IDD and iodized salt included as part of any of the following items?

35%

1 all 5: a + b + c + d + e 0.8 any combination of 4 0.6 any combination of 3 0.4 any combination of 2 0.2 a. School curriculum 0.2 b. Food-technology training programme 0.2 c. pre-service training for public employees (health and/or industry/commerce) 0.2 d. training for community health workers 0.2 e. Continuous medical education for nurses, doctors and nutritionists 0 f. none


MONITORINg AND EVAlUATION AND QUAlITY ASSURANCE (QA)/QUAlITY CONTROl (QC)

30%

Does a national monitoring system exist that tracks programme activities ?

20%

1 Yes 0 no

Are any monitoring data reported and used for corrective action/programme adjustments?

20%

1 Yes 0 no

Are rules and operating procedures for external quality control (inspections and sample taking at production and commercial level) by national authorities clearly established?

20%

1 Yes – for external monitoring at import or production level 1 Yes – for external monitoring at commercial level 1 both 0 no – they are not clearly established

Have the rules and procedures for external quality control been applied by national authorities in the past calendar year?

20%

1 Yes – they were widely applied 0.5 Yes – they were partially applied 0 no

Has the USI programme in your country been evaluated by external evaluators in the past 5 years?

20%

1 Yes 0 no 1 no – but there are plans for an evaluation in the next 2 years

Nutridash 2013 [ Global RepoRt on the pilot YeaR ]

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